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POSTER PAPER PRESENTATIONS
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Thursday, November 14, 2013  •  5:30 – 7:30 PM
Westin La Paloma Resort & Spa, Tucson, Arizona

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

Section A: Cardiology (1–8)
  B: Case Reports (9–29)
  C. Delirium (30-39)
  D: Neuropsychiatry (40-62)
  E: Pediatrics and Women's Health (63-78)
  F: Psycho-Oncology and Palliative Medicine (79-84)
  G. Psychopharmacology and Substance Abuse (85-106)
  H. Systems Based Practice (107-132)
  I. Training and Education (133-141)
  J: Transplant (142-155)
  [T] = Trainee Paper

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

Disruptions in Development: A Pioneering Course for First-Year Medical Students Taught at the Psychosomatic Interface
Presenting Author:  J. Michael Bostwick, MD, FAPM

The fact that I remember nothing of the human development course I took in medical school means it must have been as irrelevant as it was forgettable to my nascent medical career. When I received the opportunity to create from scratch a development course for Mayo first-year medical students, I vowed to do better than my medical school had done by me. I set about organizing a longitudinal course focusing on the inevitable disruptions that medical care -- no matter now necessary or skilled -- inflicts upon normal development. Over the ensuing decade I have evolved a model based on a template that organizes each class along similar lines. Where possible, I choose a topic that relates to the theme the students are currently studying in Mayo's block plan: anatomy (a videotaped interview with a future cadaver), for example, or genetics (a visit with a Huntington Disease family). Each 2½ hour segment opens with a PowerPoint talk familiarizing the students with the rudiments of an Eriksonian life stage and the basics of a medical condition with which they will need to be familiar in order to understand the day’s patient material. The case follows the mini-lecture, typically in the form of a live conversation I conduct with one of my patients or a videotaped interview I play from a large collection I continue to assemble. On occasion a teaching assistant -- a medical student who has completed the course -- will read a relevant literary excerpt as grist for the integrational mill. Finally, I facilitate a group discussion in which the students and I work to weave together the medical concepts, case material, and literature with the goal of arriving at larger truths about clinical care and medicine that can influence them positively while they are still young and impressionable. The philosophy of this model is fundamentally psychosomatic. It proceeds from an assumption that few students will become psychiatrists but all will inevitably confront the boundary at which psyche meets soma, where brain and body interface.

This poster will illustrate the components of several representative classes from the 14 that comprise the entire course sequence.

 

Section A:  Cardiology

  1. Association between PHQ-9 Score and Adverse Cardiac Outcomes in Patients Hospitalized for Acute Cardiac Disease
    Presenting Author:  Scott Beach
    Co-Authors:  Christopher Celano, Jeff Huffman

    Background: Depression has been independently associated with adverse cardiac outcomes in patients hospitalized for cardiac events. The American Heart Association recommends a two-step screening process using the Patient Health Questionaire-2 (PHQ-2) and PHQ-9 to evaluate for depression in cardiac patients. Though the Heart and Soul study demonstrated an association between PHQ-9 score and adverse cardiac outcomes in patients with heart disease, no study has demonstrated such a link in patients hospitalized for acute cardiac events. We set out to evaluate whether PHQ-9 score was predictive of cardiac readmissions over the next six months in patients hospitalized for an acute cardiac event.

    Methods: A secondary analysis of a collaborative care randomized trial was conducted. Patients were administered PHQ-9 at enrollment, and data was collected regarding cardiac readmissions over the next six months. Multivariate analysis was conducted with demographic and medical covariates including age, sex, current smoking status, history of diabetes, history of dyslipidemia, history of hypertension, baseline cardiac symptoms (using a 10-symptom symptom list), and admission diagnosis.

    Results: Of 170 subjects, 68 (40%) had readmission for a cardiac cause during the 6 month follow-up period. On multivariate analysis, initial PHQ-9 score was significantly associated with an increased risk of rehospitalization for cardiac reasons over the next 6 months (OR 1.11 [95% CI 1.01-1.22], p=0.034), with higher scores correlated with greater risk of readmission. Male sex was also associated with readmissions (OR 2.02 [95% CI 1.23-4.00], p=.043).

    Conclusion: One additional point on the PHQ-9 was associated with a 11% greater risk of cardiac readmission over the subsequent 6 months, independent of multiple relevant covariates. Our findings confirm those of the Heart and Soul study, but do so in a broader and higher-risk cardiac population. The results of this study support the use of the PHQ-9 as a screening tool for depression in patients hospitalized for acute cardiac events for both clinical and research purposes.

    Objectives:

    1. Understand why the PHQ-9 is a useful screening tool in cardiac populations.
    2. Analyze some of the factors that have bee shown to be predictive of adverse cardiac outcomes in the past.
    3. Recognize that the PHQ-9 is correlated with adverse outcomes in patients hospitalized for acute cardiac issues.

    Relevance:
    The AHA has recommended screening for depression in cardiac patients using the PHQ-9. All C-L psychiatrists should be aware of this tool and its predictive value.

     
  2. Perceptions of Treatment Predict Quality of Life in Patients with Implantable Cardioverter Defibrillators
    Presenting Author:  Kanako Ichikura
    Co-Authors:  Shiho Matsuoka, Sayaka Kobayashi, Tsuyoshi Suzuki, Katsuji Nishimura, Tsuyoshi Shiga, Shin-ichi Suzuki, Nobuhisa Hagiwara, Jun Ishigooka

    Purpose: Implantable cardioverter defibrillators (ICDs) are increasingly used for the prevention of sudden cardiac death. Though ICD save the life of patient with life-threatening ventricular arrhythmias, it leads to exacerbation of the mental burden. Many previous researches focused on experience of ICD electrical shock; however, it seemed to be unrelated to psychological symptoms. The purpose of this study was to identify the impact of perceptions about ICD treatments on QOL.

    Methods: Of all 221 ICD recipients at Tokyo Women Medical University Hospital between 2010 and 2011, 183 participated in our study. The questionnaire consisted of MOS 36-Item Short-Form Health Survey (SF-36) and Perceptions of Implantable Cardioverter Defibrillators Scale (PIS). All items of PIS contribute to four subscales: (1) Worried about electrical shock or error; (2) Concerned about limitation of activity or role; (3) Felt released from fear about heart attack or death; and (4) Felt it easy to do some activity. Multiple regression analysis was used to calculate B and 95% CIs. Variables considered in the models were sex, family, experience of ICD electrical shock, PIS and SF-36.

    Results: A total of 115 (62.8%) participants completed all questions in this study. There was no association between all other variables and Physical Component Summary (PCS) in SF-36. (1) Worried about electrical shock or error and (4) Felt it easy to do some activity was aspect of Mental Component Summary (MCS) in SF-36 independently associated with sex, family and experience of ICD electrical shock (B = -.42, 95%CI -.77 to -.06; B = -.84, 95%CI -1.52 to -.15).

    Conclusion: Our results indicated that psychological distress is predicted by both positive and negative perceptions about ICD treatment. It is, therefore, bad for patients to be overconscious about having ICDs in their bodies. ICD recipients may need distracting skills in order to live with their devices. In the future, we should develop alternative psychological care to make ICD recipients accept their illness and treatment.

    Objectives:

    1. To investigate that cognition predicts psychological distress in Japanese patients with ICD.
    2. To analyze the difference between positive and negative cognition in Japanese patients with ICD.
    3. To improve current psychological care for Japanese ICD patients.

    Relevance:
    To develop psychological care for patients with cardiac disease.

     
  3. Post-Traumatic Stress Disorder and Its Risk Factors in Japanese Patients Living with Implantable Cardioverter Defibrillators
    Presenting Author:  Sayaka Kobayashi
    Co-Authors:  Katsuji Nishimura, Kazue Kuwahara, Tsuyoshi Suzuki, Tsuyoshi Shiga, Morio Shoda, Nobuhisa Hagiwara, Jun Ishigooka

    Background: Trauma reactions, including post-traumatic stress disorder (PTSD), in patients with implantable cardioverter defibrillators (ICDs) have recently garnered increased attention. The aim of this study was to clarify the prevalence of such PTSD, its impact on patients' psychosocial distress and health-related quality of life (QOL), and risk factors for PTSD in Japanese ICD patients.

    Methods: Seventy-four ICD outpatients (63 men and 11 women; age 59.3 ± 13.6 years [mean ± SD]) completed a questionnaire that included a modified PTSD Checklist Specified [ACG1] for potentially fatal cardiac arrhythmias or ICD shocks (both appropriate and inappropriate) to assess for PTSD diagnosis, the Zung Self-Rating Depression Scale (SDS) to screen for depression, the State-Trait Anxiety Inventory (STAI)-State scale to screen for anxiety, and the Medical Outcomes Study 36-items Short Form (SF-36) to assess for health-related QOL. Sociodemographic and medical variables (e.g., underlying disease, New York Heart Association functional class, shock therapy history and medications) were compared between patients who did and did not have PTSD. The number of days since ICD implantation was 2471 ± 703.

    Results: Of the 74 patients, 28 (37.8%) had been provided with ICDs for secondary prevention, 42 (56.8%) had experienced ICD shocks, and 12 (16.2%) electrical storm (ES), which we defined as the occurrence of ≥ three separate episodes of ventricular tachycardia or fibrillation within 24-hours. We diagnosed PTSD in 19 patients (25.8%).[t2] Compared with the non-PTSD group, the PTSD group had significantly higher scores for both SDS and STAI-S and significantly lower scores in all eight subscales of the SF-36. Using multiple logistic regression analysis, we identified ES experience (OR: 6.2, 95% CI: 1.37-28.17, p < 0.018) and anxiolytic use (OR: 8.2, 95% CI: 2.09-32.24, p < 0.003) as independent risk factors for PTSD.

    Conclusions: Our study shows that PTSD in ICD patients has a significant psychosocial impact with associated impairment of both physical and mental QOL. This study suggests that patients who experience ES or take anxiolytics particularly need psychiatric/psychological interventions.

    Objectives:

    1. To estimate the prevalence of post-traumatic stress disorder (PTSD) in Japanese patients living with implantable cardioverter defibrillators (ICDs).
    2. To characterize the impact of PTSD on patients’ psychosocial distress and health-related quality of life in Japanese ICD patients.
    3. To identify the risk factors for PTSD in Japanese ICD patients.

    Relevance:
    To clarify the prevalence of PTSD, its impact on patients’ psychosocial distress and health-related quality of life, and risk factors for PTSD in Japanese ICD patients.

     
  4. Heart Rate Variability and Psychological Correlates of Patients with Non-Cardiac Chest Pain: Effects of Treatment
    Presenting Author:  Edwin Meresh
    Co-Authors:  Carmela Cowdrey, Matthew Niedzwiecki, Kathryn Morrissey, Brandon Hage, Aparna Sharma, Angelos Halaris

    Rationale: Depressive and anxiety symptoms are independent risk factors for cardiovascular morbidity and mortality. The pathophysiology underlying this comorbidity is entirely unclear. Reduced heart rate variability (HRV) is observed in many depressed and anxious patients and has been linked to increased risk of morbidity and mortality. Non-cardiac chest pain (NCCP) is comorbid with anxiety and depression. Elderly individuals with NCCP are prone to experiencing an adverse cardiac outcome [1]. We sought to assess the effects of escitalopram (ESC) on HRV in patients with NCCP compared to healthy control subjects.

    Study Design: This open-label study included 11 NCCP patients and 34 healthy controls (HC). The following instruments were used: Hamilton Depression Scale (HAM-D), Hamilton Anxiety Scale (HAM-A), Illness Behavior Questionnaire (IBQ), Somatosensory Amplification Scale (SAS) and McGill Pain Questionnaire (MPQ). Applanation tonometry using the SphygmoCor® device was used to measure baseline and post-treatment HRV. NCCP subjects received ESC and completed the ratings at weeks 2, 4, 8 and 12. Subjects underwent ECG follow-ups at the end of week 12.

    Results: Patients had a significantly lower MPQ score at week 12 (9.1) than at baseline (20.5) (p<0.001), significantly lower HAM-A score at week 12 (10.3) than at baseline (28.3) (p<0.001), and significantly lower HAM-D score at week 12 (8.9) than at baseline (19.5) (p<0.019). No significant improvement was observed in the IBQ or the SAS. Patients had a lower LF/HF ratio at baseline (1.01) than HC (1.74), although this was not significant (p=0.20). Patients at week 12 have an increased LF/HF ratio (1.52). There was no significant difference in LF/HF ratios of HC males (1.94, N=12) vs. HC females (1.43, N=22). However, male patients at baseline showed a trend toward a higher LF/HF ratio (1.61, N=4) than female patients (0.74, N=7) (p=0.08). Male patients at week 12 had a significantly higher LF/HF ratio (5.54, N=3) than female patients at week 12 (1.05, N=5) (p=.019).

    Conclusion: The use of escitalopram is clinically beneficial for NCCP patients. The Low Frequency (LF) measure reflects sympathetic and parasympathetic activity and the High Frequency (HF) measure reflects parasympathetic activity. Both LF and HF calculations in our study are uncorrected for respiratory artifacts. HRV frequency domain values do not differ significantly between the HC and NCCP group at either baseline or post treatment. However, there are sex differences. Male NCCP patients have higher LF/HF ratios than female patients at baseline and week 12, reflecting potentially higher sympathetic activity in male NCCP patients. Further studies are needed to clarify whether sex differences in HRV parameters can predict the response to SSRI treatment.

    Reference:
    1. J.G. Robinson et al: Elderly women diagnosed with nonspecific chest pain may be at increased cardiovascular risk, J Womens Health (Larchmt) 2006 Dec; 15(10):1151-60.

    Objectives:

    1. Become familiar with the psychiatric comorbidties in patients with non-cardiac chest pain (NCCP) and screen patients for depression and anxiety.
    2. Learn about SSRI treatment of patients with NCCP for pain perception, depression, and anxiety.
    3. Investigate the effect of SSRI treatment on depression, anxiety, and heart rate variability in patients with NCCP.

    Relevance:
    This presentation will provide participants with a strong understanding of heart rate variability and stimulate the audience to investigate the effect of SSRI on depression, anxiety, and heart rate variability.

     
  5. WITHDRAWN
     
  6. Outcome of Cardiac Valve Replacement in Endocarditis with IV Drug Abuse: A Case Report and Literature Review
    Presenting Author:  Natalia Ortiz
    Co-Authors:  Kiran Majeed, Amina Hanif

    Infective endocarditis (IE), usually involves the heart valves. Previous studies based on local case series estimated its annual incidence in the U.S. at about 4 per 100,000 population [1]. IE is one of the most severe complications in intravenous drug abusers (IVDA) with an incidence of 2 to 5%/year. IVDA is responsible for 5 to 20% of hospital admissions and 5 to 10% of the overall mortality rate [2]. IVDU require surgery at a younger age (39 +/- 9 years versus 54 +/- 15 years; p< 0.001). The choice of valve replacement type (bioprosthetic versus mechanical) for IVDU is controversial.

    Aim: To describe factors to consider while evaluating the candidacy and capacity to make the decision to have a valve replacement in IVDU with IE.

    Method: Case presentation and literature review of a 49 year old Latino man with IV Opioid (heroin) dependence, HCV cirrhosis and IE that needed aortic valve replacement. Psychiatry was consulted to evaluate his capacity to make that decision.

    Results: Patients with a history of IVDU require reoperation for recurrences at a significantly higher rate than the non-IVDU patients [3]. Long-term survival was similar (p = 0.78) between the younger IVDU population and the older non-IVDU population [3]. Similar rates of long-term mortality between IVDU and non-IVDU patients argue that bioprosthetic valves may be appropriate despite the younger age of the IVDU group. Few studies have reported results of surgical treatment on this population and the long-term prognosis of those patients who survive surgery.

    Conclusion: Based on this patient’s presentation with multiple comorbidities, active IVDU, poor psychosocial support, this patient was a poor candidate for valve replacement. Continued IVDU leading to recurrent endocarditis and death from drug overdose are the most common causes of morbidity and mortality. Patients who discontinue IVDU have a favorable prognosis and implantation of a mechanical prosthesis is warranted. We should make every effort to prevent these patients from returning to IVDU. Pre-operative psychiatric and social worker evaluations should be considered in valve replacement surgery in patients with IE and IVDU.

    References:

    1. Bor DH, Woolhandler S, Nardin R, Brusch J, Himmelstein DU, et al: Infective endocarditis in the U.S., 1998-2009: a nationwide study. PLoS One 2013; 8(3):e60033  doi: 10.1371/journal.pone.0060033.

    2. Carozza A, De Santo LS, Romano G, et al: Infective endocarditis in intravenous drug abusers: patterns of presentation and long-term outcomes of surgical treatment. J Heart Valve Dis 2006 Jan; 15(1):125-31.

    3. Kaiser SP, Melby SJ, Zierer A, et al: Long-term outcomes in valve replacement surgery for infective endocarditis. Ann Thorac Surg 2007 Jan; 83(1):30-5.

    Objectives:

    1. Understand the predictive factors for a successful valve replacement in IVDU.
    2. Understand the factors to consider while evaluating a patient for capacity and candidacy for heart valve replacement in IVDU.
    3. Understand the coordination of care for a patient that have a heart valve replacement and IVDU.

    Relevance:
    To learn how to educate our colleagues surgeons while making decisions about doing a valve replacement in IVDU.

     
  7. WITHDRAWN
     
  8. [T] A Model of Cardiologist Communication Strategies with Difficult Patients
    Presenting Author:  Dan Zuiches
    Co-Authors:  Crystal Jimenez, Karen Friday, John Giacomini, Bruce Bongar

    Current treatment guidelines for patients with coronary heart disease center on adopting a heart-healthy lifestyle; this includes quitting smoking, changing diet, increasing exercise, and taking medications. Studies typically find adherence to this advice is suboptimal. Preliminary research suggests cardiologists find discussions with patients about non-adherence “difficult” yet few adopt patient-centered approaches despite evidence of their greater effectiveness. According the Theory of Planned Behavior, individuals perform actions intentionally based on beliefs about the future consequences, and their perception of behavioral control. Using this theoretical model, this study explores the beliefs and behaviors of cardiologists working with coronary heart disease (CHD) patients they find “difficult.” Understanding the factors influencing cardiologists’ perceptions of difficult patient encounters is critical for assessing how they situate, conceptualize, and experience non-adherence, depressive symptoms and other patient behaviors. Furthermore, it helps to predict how they will behave during patient visits. Preliminary findings suggest cardiologists’ communication strategies are influenced by their beliefs about their own efficacy at increasing patient trust and clinical understanding. The goal of this research is to expand knowledge about the specific challenges to cardiologists working with CHD patients and identify future avenues for health reform, support, and physician training.

    Objectives:

    1. Describe the types of patient encounters cardiologists find challenging.
    2. Investigate the need to facilitate consultation referrals from cardiologists to consultation-liaison psychiatrists; such to facilitate such referrals in a more timely and expeditious fashion.
    3. Describe the opportunities to engage cardiologists in addressing patient mental health issues.

    Relevance:
    The presentation offers insight into the adaptive and maladaptive cognitions of cardiologists in community practice regarding patient nonadherence. This insight can be used to identify opportunities improve psychosomatic medicine.

     

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Section B:  Case Reports

  1. [T] How to Assess for Malingering in the Emergency Room: A Case Example
    Presenting Author:  Meredith Caitlin Brady
    Co-Author:  Lorin Scher

    Background: Numerous state and county budget cuts due to the nation's economic downturn have forced many patients to utilize the emergency room for mental healthcare. While most patients who present to the E.R. for mental health-related reasons have a legitimate psychiatric crisis, this is not always the case. As the number of patients seeking care in the E.R. has increased, so has the number of patients who feign symptoms for secondary gain (i.e., malingering).

    According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Revised (DSM-IV-TR), malingering is "...the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives..."[1]. Despite a relatively simple definition, detecting malingered symptoms can be difficult, especially in the busy emergency setting. It is a diagnosis of exclusion, often avoided due to fears of retaliation and diagnostic uncertainty.

    Despite doctors' reluctance to diagnose malingering, it is a real problem, especially in the emergency room. Research suggests that as many as 13 percent of patients in the emergency room feign illness, and that their secondary gains most often include food, shelter, prescription drugs, financial gains; and avoidance of jail, work, or family responsibilities.[2]

    Purpose and Methods: This poster presentation will provide emergency clinicians with recommendations and strategies to better assess for malingering in the emergency room. Using case presentations, we will emphasize objective tests used to help detect feigned symptoms in a fast-paced environment. We will also summarize the literature examining typical versus atypical symptoms of psychosis in an effort to highlight presentations suggestive of malingering.

    Results: The most appropriate psychometric tests to detect malingering in the E.R. include the Millar Forensic Assessment (100% specific, 93% sensitive), Rey's 15-Item Visual Memory Test (100% specific, 40% sensitive), and Coin-In-The-Hand Test (87.5% 92.5%).

    Conclusion: Malingering is a very real problem that impacts emergency room clinicians. The detection of patients who feign symptoms is complex, but possible, even in the fast paced emergency setting. Identification of malingering behaviors will not only save time and money, but will also help to allocate limited resources to people with legitimate mental health crises.

    References:

    1. Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.). Washington, DC: American Psychiatric Association; 2000.

    2. Yates BD, et al: Feigned Psychiatric Symptoms in the Emergency Room. Psychiatric Serv 1996; 47(9):998-1000.

    3. Gunn J, Taylor P: Forensic Psychiatry: Clinical, Legal and Ethical Issues. Oxford, England: Butterworth-Heinemann, 1998.

    4. Reccoppa L: Mentally ill or malingering? 3 clues cast doubt. Current Psychiatry 2009; 8(12).

    5. Resnick P, Knoll J: Faking it: how to detect malingered psychosis. The Journal of Family Practice 2005; 4(11).

    Objectives:
    1. Distinguish typical versus atypical symptoms of psychosis to better detect malingered behaviors.
    2. Understand the application and utility of brief objective tests (i.e. M-FAST, Reys, and CIH) to screen for malingering.
    3. Learn how to best approach patients suspected of malingering in the emergency room.

    Relevance:
    This presentation is relevant to psychiatrists, E.R. physicians, and clinicians who work in the emergency department. It is also relevant to other fields of medicine in which individuals malinger.

     
  2. [T] Beyond the Binge: Identifying Other Problematic Eating Behaviors in a Male Bariatric Surgery Candidate
    Presenting Author:  Shannon Clark
    Co-Authors:  Lisa Miller, Anne Eshelman

    Purpose: Emotional eating and food addiction are two problematic eating behaviors that contribute to obesity. However, while binge eating is often evaluated for prior to bariatric surgery, these constructs may be overlooked. This case is an example that highlights the importance of evaluating non-diagnosable eating behaviors who would otherwise not meet criteria for an eating disorder. Additionally, this case illustrates the importance to assess problematic eating behaviors across gender.

    Case Presentation: Mr. G, age 45, underwent a psychological evaluation prior to bariatric surgery. He considered bariatric surgery for 1.5 years and stated that his quality of life was greatly declining due to his weight.

    Mr. G reported that he used food to cope with negative emotions. Specifically, he recognized that he ate when under stress, bored, and when feeling depressed. He particularly noticed problems with sweets, salty foods, cookies, and fast food. Though Mr. G endorsed many symptoms of Binge Eating Disorder (BED), he did not meet full criteria. However, on measures of emotional eating and food addiction, Mr. G scored higher than what was seen in an obese sample suggesting that although he did not meet criteria for a diagnosable eating disorder, his emotional and psychological relationship to food was strong. Additionally, he reported a great deal of stressful events throughout his life and had few coping skills, which ultimately led to his obesity status. Therefore, he was encouraged to complete a cognitive-behavioral weight management group prior to having bariatric surgery.

    Conclusions: This case highlights the need to assess bariatric surgery candidates for non-diagnosable eating behaviors. Additionally, while it is thought that females commonly experience these problems, this case illustrates the importance of not minimizing problematic eating behaviors in males. Had Mr. G only been evaluated for diagnosable eating disorders, he may not have received help to manage these behaviors. Additionally, Mr. G’s insight into the role that food played in decreasing stress, increasing mood, and coping with trauma led to his access into a 6-week intervention program tailored to addressing problematic eating behaviors.

    References:

    1. Clark SM, Saules KK: Validation of the Yale Food Addiction Scale among a weight-loss surgery population. Eating Behaviors 2013; 14(2):216-219.

    2. Gearhardt AN, White MA, Potenza MN: Binge eating disorder and food addiction. Current Drug Abuse Reviews 2011; 4(3):201-207.

    3. Tanofsky MB, Wilfley DE, Spurrell EB, Welch R, Brownell KD: Comparison of men and women with binge eating disorder. International Journal of Eating Disorders 1997; 21(1):49-54.

    Objectives:
    1. Investigate emotional eating and food addiction in a bariatric surgery population.
    2. Explore gender concerns in assessing problematic eating.
    3. Identify problematic eating behaviors beyond those included in diagnosis psychiatric disorders.

    Relevance:
    This case highlights the importance of evaluating non-diagnosable eating behaviors otherwise not meeting criteria for an eating disorder. Additionally, it illustrates the importance to assessing problematic eating behaviors across gender.

     
  3. [T] Management of Major Depression in a Patient with Blood Dyscrasias
    Presenting Author:  Erika Concepcion
    Co-Authors:  Daniel Safin, David Edgcomb, Nancy Maruyama

    Introduction: Thrombocytopenia and other blood dyscrasias have been associated with use of antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) and other psychotropic medications. However, limited data is available on the effects of antidepressants on individuals with pre-existing blood dyscrasias who will receive bone marrow suppressive chemotherapy treatment. We report on the treatment of a man with acute myeloid leukemia meeting criteria for major depressive episode.

    Case Report: Mr. G is 48 year old man with a history of major depressive disorder who presented with one week of fever, found to have a WBC count of 87 k/µl and platelets of 24 k/µl. Bone marrow biopsy revealed acute myeloid leukemia, a conversion from chronic myeloid leukemia diagnosed ten months prior. Bone-marrow suppressing treatment with idarubicin and cytarabine was planned. At time of consultation, the patient endorsed depressed mood, insomnia, anhedonia, lack of energy, difficulty in concentration, and loss of appetite. A brief review of the adverse drug effects on the online reference, Lexi-Comp, did not reveal any contraindication to the use of mirtazapine for symptoms of insomnia, lack of appetite, and depressed mood in the context of his thrombocytopenia. The patient was started on mirtazapine 7.5mg at bedtime and received one dose. Concern for iatrogenic contribution to blood dyscrasia fueled a search of ovidMedline and PsycINFO on treatment of depression in this particular medically compromised population. Mirtazapine was discontinued as there were reports of mirtazapine associated thrombocytopenia. The patient was started on bupropion for depressed mood and decreased energy. Zolpidem was started for insomnia.

    Discussion: We review the psychiatric literature on the relationship between antidepressants medications and various hematologic disorders. We discuss the risks and benefits which must be weighed when selecting antidepressants in the setting of acute blood dyscrasias.

    References:

    1. Andersohn F, Konzen C, Bronder E, Klimpel A, Garbe E: Citalopram-induced bleeding due to severe thrombocytopenia. Psychosomatics 2009; 50:297-298.

    2. Balon R, Berchou R: Hematologic side effects of psychotropic drugs. Psychosomatics 1986; 27:119-120, 125-127.

    3. Halperin D, Reber G: Influence of antidepressants on hemostasis. Dialogues in Clinical Neuroscience 2007; 9:47-59.

    4. Liu X, Sahud MA: Glycoprotein IIb/IIIa complex is the target in mirtazapine-induced immune thrombocytopenia. Blood, Cells, Molecules, and Diseases 2003; 30:241-245.

    5. Oyesanmi O, Kunkel E, Monti D, Field H: Hematologic side effects of psychotropics. Psychosomatics 1999; 40:414-421.

    6. Stübner S, Grohmann R, Engel R, et al: Blood dyscrasias induced by psychotropic drugs. Pharmacopsychiatry 2004; 37:70-78.

    Objectives:

    1. Be aware of hematologic side effects of antidepressants.
    2. Be aware of risks and benefits of initiation or continuation of antidepressants in individuals with preexisting blood dyscrasias.
    3. Be able to assist patients in making informed decisions regarding treatment options.

    Relevance:
    The participant will be able to consider best practices when prescribing antidepressants in the context of blood dyscrasias.

     
  4. [T] Acetaminophen Overdose in the Context of Roux-en-Y Gastric Bypass: Implications of Bariatric Surgery on Drug Absorption
    Presenting Author:  Renu Culas
    Co-Authors:  Deniz Eker, Anna Kreiter, Dickson Jean, Daniel Safin, Kenneth Ashley, Nancy Maruyama, Joel Wallack

    Introduction: It is estimated 113,000 bariatric surgeries are performed annually in the United States. The potential for these procedures to cause nutritional deficiencies is well known. Less is known about the ability of these procedures to alter drug absorption. The effect of gastric bypass on drug absorption is variable and appears to be drug specific.

    Methods: We discuss the management of a woman six months post roux-en-Y gastric bypass who overdosed on acetaminophen and review the literature on drug absorption following gastric bypass.

    Case Report: Ms. C is 54 yr old woman with a past history of major depressive disorder, recurrent severe with psychotic features, admitted to the medical intensive care unit (MICU) following an acetaminophen overdose prompted by persecutory auditory hallucinations. She had a past medical history of Roux-en-Y gastric bypass. The MICU staff started N-acetylcysteine and requested a psychiatry consult for assistance with management. They predicted the acetaminophen absorption would be reduced because of the gastric bypass. They expected the hepatic sequelae from the overdose would be limited. Contrary to expectations the transaminases were mildly elevated on admission but rose to an AST of 6243 and ALT of 7834 by day three. This rise in transaminases followed the expected timeline for an acetaminophen overdose in a patient without gastric bypass.

    On mental status exam the patient presented with anxiety, transient auditory hallucinations but no suicidal ideation. By day three the patient reported constant anxiety and persecutory auditory hallucinations similar to those that led her to overdose. Due to elevated transaminases and a prolonged QTc of 599 on ECG, treating the patient with an antipsychotic was deemed high risk. She was treated with lorazepam until day six when the transaminases began to trend down and her QTc was below 450. At this time she was started on low dose haloperidol and closely monitored.

    Discussion: This case highlighted the confusion around drug absorption following gastric bypass that is increasingly encountered by psychosomatic medicine physicians. We review the literature on the effect of the different types of gastric bypass surgery on acetaminophen and psychotropic drug absorption. We also discuss the management of this patient's psychiatric symptoms and provide recommendations for the selection of psychiatric medications in the context of her bariatric surgery.

    References:

    1. Seaman JS, Bowers SP, Dixon P, et al: Dissolution of common psychiatric medications in a Roux-en-Y gastric bypass model Psychosomatics 2005; 46(3).

    2. Malone M: Altered drug disposition in obesity and after bariatric surgery. Nutr Clin Pract 2003; 18(2):131-135.

    3. Padwal R ,Brocks D, Sharma AM: A systematic review of drug absorbtion following bariatric surgery and its theoretical implications. Obese Rev 2010; 11(1):41-50.

    4. Hamad GG, Helsel JC, Perel JM, et al: The effect of gastric bypass on the pharmacokinetics of serotonin reuptake inhibitors. Am J Psychiatry 2012; 169(3):256-263.

    Objectives:

    1. Be aware of the pattern of drug absorption for acetaminophen following gastric bypass.
    2. Be aware of the pattern of drug absorption for psychotropic medication following gastric bypass.
    3. Be aware of the special considerations necessary when prescribing medication following bariatric surgery.

    Relevance:
    The participant will consider best practices when prescribing psychotropic medication following bariatric surgery.

     
  5. [T] Fatal Apathy: A Case Report and Review of Abulia, Apathetic Indifference, and Amotivation in a Young Man with Diabetic Ketoacidosis and Insulin Noncompliance
    Presenting Author:  Dustin DeMoss
    Co-Author:  James McConville

    Background: Diabetic ketoacidosis is a life-threatening disease complication that can have various clinical presentations including neurologic sequelae. Abulia (Greek, meaning “un-will”) describes a lack of will or initiative and can be a neuropsychiatric symptom of frontal lobe, basal ganglia, anterior cingulate or caudate nuclei injury. It can occur in cerebrovascular injury, neurodegenerative disease, depression, schizophrenia, and rarely metabolic neurologic injury.

    Case report: Mr. M is a 32 year-old man seen in the emergency department one month prior to presentation for fatigue, polyuria, and polydipsia. He was diagnosed with diabetes mellitus with extremely poor blood glucose control with peripheral neuropathy and a hemoglobin A1c of 22.5%. He was referred to an outpatient endocrinologist, counseled and started on insulin.

    Two weeks later he was admitted to an academic medical center for 24 hours of left hand weakness. He acknowledged he had not been taking his insulin because “[He was] not feeling like it” and because he believed “it wouldn’t change anything.” He was minimally cooperative and gave non-committal and evasive answers such as “what does it matter” and “I don’t care.” His family indicated that over the last few weeks he had become more isolative and was “not his usual self.” Physical exam revealed waxy flexibility, left sided neglect, and inability to perform appropriate clock drawing. Mental status exam demonstrated affective flattening, cognitive impairment and poor insight, but no other clear evidence of depression and no suicidal ideation. Laboratory data revealed an elevated glucose of 534mg/dl, an elevated anion gap metabolic acidosis and ketoacidosis. His blood sugar control appeared to have not improved since last admission. An MRI was negative for any acute intra-cerebral events. After aggressive treatment of his diabetes with insulin and diabetes education the patient’s hand numbness resolved, but his lack of appreciation for the seriousness of his condition persisted. The patient was discharged with close follow up with his established endocrinologist.

    One week after discharge, the patient had a seizure and was re-admitted to the ICU. He was found to be in DKA and despite appropriate therapy, continued to have seizures requiring intubation. Unfortunately Mr. M suffered complications including a pneumothorax and a non-ST segment elevation myocardial infarction. He expired about five weeks after of his diagnosis of diabetes was made.

    Discussion: Mr M’s abulia appeared to be a contributor to his total medication noncompliance and persistently elevated blood glucose levels that led to progressive complications and early mortality. Targeting symptoms of apathetic indifference, abulia, depression and amotivation for psychiatric therapeutic intervention can be beneficial in improving compliance in medically complex patients.

    Objectives:

    1. Identify clinical features and psychiatric manifestations of diabetic ketoacidosis and review of the mortality data of noncompliance diabetics.
    2. Review the potential psychopharmacologic and behavioral interventions for abulia and apathetic indifference to medical treatment in medically ill patients.
    3. Discuss the role of the consultation psychiatrist in motivation assessment in medically non-compliant patients

    Relevance:
    Targeting symptoms of apathetic indifference, abulia, depression and amotivation for psychiatric therapeutic intervention can be beneficial in improving compliance in medically complex patients.

     
  6. Malignant Catatonia or Neuroleptic Malignant Syndrome: A Diagnostic Dilemma
    Presenting Author:  Zeeshan Faruqui
    Co-Authors:  Joshua Chandy, Rachna Raisinghani, Abdel Meguid, Alexandru Trutia

    Background: Malignant catatonia is a subtype of catatonia characterized by autonomic instability and severe hyperthermia in addition to distinct motor and behavioral signs. It is associated with underlying neurologic, medical, or psychiatric conditions. We present a case of a 61 year old female with schizophrenia with prolonged course of malignant catatonia minimally responsive to benzodiazepines, hospital course complicated by neuroleptic malignant syndrome, concurrent medical complications, and resolution of catatonic signs with a series of electroconvulsive treatments.

    Case: Ms. X, a 61 year old African American female with schizophrenia, was admitted to the psychiatric unit from the ER with complaints of restlessness, mutism and mild rigidity. She was taking Perphenazine 4 mg QAM and 8 mg QPM at the time. On the inpatient unit, her exam revealed mutism, immobility, waxy flexibility, upper extremity stiffness, and facial grimacing. Her blood work was significant for mild hyperglycemia and CK of 1453u/l which dropped to 368u/l with IV hydration. In addition, she had mild hypertension. A head CT revealed generalized volume loss, basal ganglia calcification and a lobular hyperdensity at the angle of left mandible, 2.1 in diameter, and without soft tissue component.

    She was started on oral lorazepam 1mg every 4 hours, and was continued on her home anti-hypertensive medications. Perphenazine was held. With no evidence of resolution of her clinical signs after two days, lorazepam was stopped. A subsequent trial of low dose Quetiapine raised her CK to 1269 u/L. An EEG ruled out any seizures to explain the rising CK. She continued to display waxy flexibility along with elevated systolic blood pressures peaking at 209mmHg, necessitating transfer to Internal medicine. She was moved to the ICU as her clinical picture further deteriorated. She developed fever of 103.82 F, leukocytosis of 29.3 x 10^9/L, labile blood pressure and had poor oral intake. Her exam revealed right submandibular sialadenitis, with cellulitis extending into the neck and right cheek. She was treated with IV antibiotics and electively intubated to protect airway. As blood pressure stabilized in the ICU, she received 14 sessions of bitemporal ECT which resolved mutism and rigidity. By the end of ECT treatment, she was able to make eye contact, speak a few words, and follow simple commands.

    Discussion: The definitive pathophysiology of catatonia and neuroleptic malignant syndrome is currently unknown. Given the similarities in various aspects of the presentation of both syndromes, it has been hypothesized that each syndrome is a manifestation of the same underlying pathophysiological process with varying degrees of severity. The two syndromes may be related as they have been noted to share risk factors.

    Objectives:

    1. Identify presenting sings and symptoms of neuroleptic malignant syndrome and Catatonia in obscure clinical presentations as in this case.
    2. Efficiently investigate the various medical comorbidities that arise with neuroleptic malignant syndrome and catatonia and manage accordingly.
    3. Apply the clinical approach used in this case to manage other various presentations of catatonia and neuroleptic malignant syndrome and use ECT safely and efficiently.

    Relevance:
    We present this case as it was a diagnostic dilemma for the physicains involved in the care of the patient, and to help our colleagues learn from our experiences.

     
  7. [T] A Case of Natalizumab-Induced Depression and Acute Suicidality in a Patient with Crohn’s Disease
    Presenting Author:  Kyle Lavin
    Co-Author:  Stephen Nicolson

    Background: Patients with inflammatory bowel disease (IBD) have a decrease of health-related quality of life as well as an increase in rate of death by suicide. Furthermore, two cases of treatment-related suicide with infliximab (monoclonal antibody against TNF-alpha) have been reported in the literature. We report a case of a woman treated with natalizumab (monoclonal antibody against CAM alpha 4-integrin) who developed acute suicidal ideation. Inflammatory cytokines have been shown to have a downstream effect on GABA and glutamate and similar effects of natalizumab may contribute to adverse psychiatric effects.

    Case Report: A 38 yo Caucasian female with a past psychiatric history of 1 episode of depression 8 years ago, with no current treatment, presented to the hospital for evaluation of depression and suicidal ideation. She developed these symptoms after her 5th infusion of natalizumab for treatment of Crohn's disease.

    The patient had failed multiple previous treatments for her severe, fistulizing, Crohn's disease. She began her natalizumab infusions on 4/2/12 with good response of her IBD. However, she developed multiple side effects, including headaches and rash, although no mood symptoms initially. One week after receiving her 5th infusion on 9/20/12, she developed acute onset depressive symptoms including insomnia, decreased energy, decreased concentration, and anhedonia.

    After 4 weeks of worsening depression culminating in suicidal ideation, the patient was admitted to the psychiatric hospital on 11/08/12 for acute stabilization. After discussion with her gastroenterology team, it was felt that her symptoms were likely related to administration of natalizumab. However, given the refractory nature of her IBD and the effectiveness of the natalizumab infusions, the patient elected to continue treatment with natalizumab. In order to address her depression and intrusive suicidal thoughts she was treated with mirtazapine 15mg qhs, and risperidone 0.5mg bid. She responded well and weekly psychotherapy was arranged with the IBD clinic, with close follow-up for monitoring of possible return of psychiatric symptoms.

    Conclusion: While there are several confounders, including the patient's history of depression, this case report illustrates the challenges of managing a chronic medical condition such as Crohn's disease. Crohn's disease carries a significant increase in risk of depression and suicidality, and often requires treatments that can have adverse effects on mood. Previous reports have documented cases of suicide related to infliximab. Although natalizumab has been linked with an increased risk of progressive multifocal leukoencephelopathy, this is the first report of suicidality associated with the administration of natalizumab. Further research should be done to assess the risk of suicide in patients treated with natalizumab and other monoclonal antibodies. Clinicians should be aware of the risk of depression and suicide when treating the IBD population.

    Objectives:

    1. Learn about inflammatory bowel disease (IBD) and association with psychiatric conditions.
    2. Understand the possible risk of depression and suicidality related to the use of monoclonal antibodies in IBD.
    3. Consider the risks and benefits of choosing to continue a medication to treat refractory disease that has been felt to have caused suicidal ideation.

    Relevance:
    Providers must be aware of possible side effects of medications used to treat IBD and that monoclonal antibodies such as natalizumab may be associated with psychiatric side effects

     
  8. [T] Bad Voodoo: A Case Report of Acute Hyponatremic Psychosis in a New Orleanian Faith Healer
    Presenting Author:  James McConville
    Co-Authors:  Robert Harvey, Lily Ngotran

    Case Report: A New Orleanian woman in her 30s was brought to the Emergency Department at an academic medical center after her roommate found her sitting in a bathtub filled with what appeared to be blood, wearing red-stained clothes. Efforts by emergency medical personnel to find a source of bleeding were unsuccessful, raising a fear that an unknown person had been injured. On presentation to the ER she was agitated, psychotic, disorganized and irrational, requiring restraints. She kept both legs propped up on the railing and repeatedly stated “Please do not let me go offline.” On psychiatric interview the patient reported she speaks to “spirit mediums” who told her to drink a lot of water to “expel all the toxins.”

    Medical workup included a negative head CT, drug and alcohol screening. Laboratory workup revealed acute euvolemic hypotonic hyponatremia with a serum sodium of 120 mmol/L and calculated osmolality of 247 mOsm/kg. Her renal function was intact and her urine appeared to be maximally diluted with a urine osmolality of 83 mOsm/kg and a urine sodium of 14 mmol/L.

    Collateral information indicated that the patient was a practicing medium trained by a shaman in Africa. One month before this admission she developed a fear that she had a deep vein thrombosis and began cleansing herself. She began taking herbal medications including “Dragon’s blood” (resinous extract from fruits grown in Sumatra) and “Skull Caps” (a plant scultellaria lateriflora). She also had been ingesting large amounts of water, giving herself daily enemas for the last few weeks.

    Patient was admitted to the ICU and worked up medically. Her psychosis was treated with risperidone. Her medical workup revealed psychogenic polydipsia. Following water restriction, her hyponatremia rapidly improved. Her psychosis resolved fully. She was counseled and discharged the following day on no psychiatric medication.

    Discussion: Severe hyponatremia may present with delirium, psychosis, ataxia, seizures, obtundation respiratory depression and coma. Hyponatremia delirium may result from any cause of acute hyponatremia, including cardiac, hepatic, renal, endocrinologic, and pharmacologic. Acute hyponatremic psychosis has differential diagnosis which includes SIADH, drug induced, or primary polydipsia as a complication of mental illness. Differentiating between these causes is critical to the evaluation and safe treatment of the patient’s hyponatremia and psychiatric symptoms.

    Objectives:

    1. Identify the clinical features of secondary psychosis and delirium.
    2. Learn the differential diagnosis of acute hyponatremia psychosis in medical-surgical patients without known mental illness.
    3. Learn the medical workup and appropriate treatment of SIADH and psychogenic polydipsia.

    Relevance:
    Acute psychosis in the presence of hyponatremia may represent a primary or secondary psychiatric symptom. Differentiating between these is critical to treatment.

     
  9. [T] Escitalopram-Induced Progressive Cervical Dystonia
    Presenting Author:  Robert Morgan
    Co-Author:  Tamara Dolenc

    Purpose: Dystonic reactions [1] have been commonly reported with antipsychotics but occur rarely with selective serotonin reuptake inhibitors (SSRIs). Escitalopram is an SSRI that has been infrequently associated with movement disorders. Literature review identified a single case report of paroxysmal cervical dystonia [2] and one report of oculogyric dystonia [3]. We present a patient who developed escitalopram-induced progressive cervical dystonia.

    Methods: A 78-year-old man with recurrent major depressive disorder and anxiety disorder, not otherwise specified, was initially seen in the emergency department for progressively worsening neck stiffness and pain associated with an upward dose titration of escitalopram. His ensuing clinical course was followed through chart review over the subsequent six months.

    Results: Our patient was initially treated with escitalopram 5 mg daily for 4 weeks, which resulted in remission of depressive symptoms. As his anxiety persisted, escitalopram dose was increased to 10 mg daily. Over the course of the next weeks he developed mild neck stiffness which was attributed to ongoing anxiety, and escitalopram dose was further increased to 15 mg daily. He presented to the emergency department five days later with prominent neck stiffness, markedly decreased range of neck motion, and mild persistent neck flexion. Comprehensive evaluation failed to identify underlying medical, neurologic, or toxic causes of dystonia. He was treated with diphenhydramine 75 mg intravenously which resulted in rapid symptom improvement. Escitalopram was discontinued. In the following two weeks his cervical dystonia completely resolved. He declined rechallenge with escitalopram or another antidepressant. His anxiety was successfully treated with low-dose clonazepam and depression remained in remission.

    Conclusions: Our patient developed a reversible dose-dependent dystonic reaction with escitalopram. Clinicians should be aware of this rare but potentially debilitating side effect when treating patients with this medication. To our knowledge, this is the first case report of a progressive dystonia associated with escitalopram.

    References:

    1. Ledoux MS: Dystonia: Phenomenology. Parkinsonism Relat Disord 2012; 18 Suppl 1:S162-4.

    2. Garcia Ruiz PJ, Cabo I, Bermejo PG, Carnal P: Escitalopram-Induced paroxysmal dystonia. Clinical Neuropharmacology 2007; 30(2):124-126.

    3. Patel OP, Simon MR: Oculogyric dystonic reaction to escitalopram with features of anaphylaxis including response to epinephrine. Int Arch Allergy Immunol 2006; 140:27-29.

    Objectives:

    1. Recognize that movement disorders can be associated with selective serotonin reuptake inhibitors.
    2. Identify dystonic reactions when seen as a side effect of escitalopram.
    3. Use the above knowledge to better integrate risks and benefits of utilizing escitalopram in clinical practice for the treatment of depression and anxiety.

    Relevance:
    Dystonic reaction is an uncommon side effect of escitalopram and its occurrence may be mistaken for a feature of the underlying disorder.

     
  10. WITHDRAWN
     
  11. [T] Challenges of Non-Psychiatric Psychosis: A Case Report
    Presenting Author:  Padmapriya Musunuri
    Co-Authors:  Gibson George, Ajita Mathur, Carolina Retamero

    Introduction: It has been reported that brain tumors can be neurologically silent and present only with psychiatric symptoms like anxiety, depression, psychosis, or personality changes. Studies have shown that tumors affecting the frontal lobe, temporal lobe, hippocampus, thalamus, and hypothalamus commonly present with these psychiatric manifestations. Temporal lobe lesions have been reported to lead to schizophrenia-like psychosis. This type of psychosis seen in temporal lobe tumors was first described by Walther-Buel and Gudietti. There are a variety of neurological or medical conditions that can present only with psychiatric symptoms. Drugs and medications are the other organic causes of psychiatric symptoms.

    Purpose: We present the case of a 75-year-old gentleman with no significant past psychiatric history who presented with acute onset of anxiety, mood lability, hallucinations, and paranoid delusions. There were no focal neurological deficits and CT scan was normal except for an old craniotomy scar, but a subsequent MRI revealed a high-grade glioma in the right mesial temporal lobe.

    Method: The authors performed a retrospective review of this patient’s chart. A PubMed and Psychiatry Online literature search was conducted using the search terms “brain tumor and psychosis”, “temporal lobe tumor and psychosis”, “temporal lobe tumor and schizophrenia” and “organic psychosis”.

    Discussion: Although a craniotomy scar was noticed on CT, neither he nor his family had any recollection of any surgeries in the past, and was not reported on presentation. He had no prior psychiatric symptoms and no significant past medical history. His symptoms were acute in onset and progressive. The tumor was deemed inoperable by neurosurgery and patient was discharged home with antiepileptic and antipsychotic with outpatient neurology and psychiatry follow-up. The patient showed improvement in his psychotic symptoms on low dose of risperidone.

    Prior studies have shown that acute and late-onset of psychiatric symptoms should raise high suspicion for medical or neurological causes. Additionally, acute changes in mental status, atypical presentation, poor response to treatment or waxing and waning of symptoms should lead to suspicion of organic etiology and necessitate immediate neurological evaluation. It has also been recommended that any patient over 40 years of age with late onset of psychiatric symptoms or acute neurobehavioral deterioration warrants neuroimaging of the brain.

    References:

    1. Galasko D, Kwo-On-Yuen PF, Thal L: Intracranial mass lesions associated with late-onset psychosis and depression. Psychiatr Clin North Am 1988 Mar; 11(1):151-66.

    2. McIntyre HD, McIntyre AP: Am J Psychiatry 1942; 98:720-726.

    3. Lautenschlager NT, Förstl H: Organic psychosis: insight into the biology of psychosis. Curr Psychiatry Rep 2001 Aug; 3(4):319-25.

    4. Betul O, Ipek M: Brain tumor presenting with psychiatric symptoms. J Neuropsychiatry Clin Neurosci 2011; 23:E43-E44.

    5. Gal P: Mental symptoms in cases of tumor of temporal lobe. Am J Psychiatry 1958; 115:157-160.

    Objectives:

    1. To consider identifying and treating medical/organic causes for new onset or worsening psychiatric symptoms.
    2. To emphasize the importance of investigating for medical or neurological conditions before making a definitive psychiatric diagnosis.
    3. To demonstrate risk factors that should raise high suspicion of a medical or neurological cause for psychiatric presentation.

    Relevance:
    Psychiatrists are often consulted for patients with psychiatric symptoms on medical floors. Psychiatrists are still responsible for screening patients for non-psychiatric causes of these symptoms before treating the psychiatric illness.

     
  12. Psychotic Syndrome after Starting Antiretroviral Therapy: A Case Report
    Presenting Author:  Ricard Navinés
    Co-Authors:  Aracelli Rousaud, José Moreno-España, Jordi Blanch

    It is very well known that various antiretroviral agents may induce neuropsychiatry disorders. [1] The more frequent symptoms include insomnia, disturbing dreams, nervousness and depression. Other antiviral agents such as interferon [2] may precipitate similar neuropsychiatry effects. Psychotic reactions have also been described, mostly associated with manic affective states. [3] The diagnostic distinction between a primary and an induced psychiatric disorder is critically important, because each disorder requires a different approach.

    We describe a non-affective psychotic syndrome associated with the beginning of an antiretroviral regimen containing tenofovir plus emcitrabine in a woman with several psychiatric vulnerability factors. Given the temporal relationship between the appearance of symptoms and the beginning of the antiretroviral therapy we believe that antiretroviral regimen induced the psychotic syndrome. Moreover, suppression of these antiretroviral agents led to remission of symptoms, but not the amisulpiride and zyprasidone treatment.

    Psychiatric vulnerability and current treatment of patients prior to initiate an antiretroviral regimen should be taken into account to carry out a closer follow-up of possible neuropsychiatric side effects.

    References:

    1. Allavena C, Le Moal G, Chistophe M, Chiffoleau A, Raffi F: Neuropsychiatric adverse events after switching from an antiretroviral regimen containing efavirenz without tenofovir to an efavirenz regimen containing tenofovir: a report of nine cases. Antiviral Therapy 2006; 11:263-5.

    2. Navinés R, Castellví P, Solà R, Martín-Santos R: Peginterferon and ribavirin-induced bipolar episode successfully treated with lamotrigine witout discontinuation of antiviral therapy. Gen Hosp Psychiatry 2008; 30:387-9.

    3. Blanch J, Corbella B, García F, Parellada E, Gatell JM: Manic syndrome associated with efavirenz overdose. Clin Infect Dis 2001; 15:270-1.

    Objectives:

    1. The diagnostic distinction between a primary and an-induced psychotic disorder is critically important, because each disorder requires a different approach.
    2. The differential diagnosis is much more complex in HIV patient, as HIV infection itself or other HIV-associated illnesses may present with psychiatric symptoms.
    3. Psychiatric vulnerability and current treatment of patients prior to initiate an antiretroviral regimen should be taken into account to carry out a closer follow-up of possible neuropsychiatric side effects.

    Relevance:
    This case highlights again the need for multidisciplinary team involvement to manage the complex medical, psychiatric and psychosocial issues that people with HIV experience.

     
  13. [T] Zolpidem-Induced Galactorrhea via GABAergic Inhibition of Dopamine: A Case Report
    Presenting Author:  Daniella Palermo
    Co-Author:  Adekola Alao

    Introduction: Insomnia, which can be defined as difficulty in falling and/or remaining asleep or simply reduced quality of sleep, can be secondary to a physical or psychiatric condition. The prevalence of insomnia has been estimated to be as high as 32 to 33% of the population. Non-benzodiazepines such as zolpidem have become more commonly used due to their more favorable adverse effect profile. In this report, we will describe a case of zolpidem-induced galactorrhea. We will also explore the mechanism leading to galactorrhea in this patient.

    Case Report: The patient is a 29-year-old woman with a history of post-traumatic stress disorder (PTSD) as well as alcohol abuse in sustained remission who presented with PTSD-associated insomnia. She was started on zolpidem 5 mg po qhs. Two months after the initiation of zolpidem treatment, the patient presented with breast tenderness and galactorrhea. Zolpidem was discontinued and the galactorrhea resolved after two weeks. A serum prolactin level was drawn shortly after discontinuation of zolpidem and was measured to be 15.67 mg/ml.

    Discussion: Zolpidem has a high affinity and is a full agonist at the α1- containing GABAA receptors, with reduced affinity for those containing the α2- and α3- GABAA receptor subunits and minimal affinity for α5 receptor subunit. Due to its selective binding, zolpidem has been found to have very weak anxiolytic, muscle relaxing and anticonvulsant properties while having very strong hypnotic properties. Psychotropic drugs have been well recognized to produce hyperprolactinemia. However, there has been no reported case of zolpidem-induced hyperprolactinemia. Specifically, zolpidem has been noted to activate GABAergic neurons within the ventral tegmental area (VTA), where there is a sizable population of GABAergic neurons. These GABAergic neurons regulate the firing of dopaminergic counterparts, also located in the VTA, which send projections throughout the brain. This inhibition results in a decrease in the dopaminergic inhibitory influence on prolactin and an increase in prolactin releasing factors which act on the anterior pituitary, leading to hyperprolactinemia and thus galactorrhea.

    Conclusion: Pharmacologically induced hyperprolactinemia may be a problem of underestimated prevalence due to the lack of externally visible symptoms as well potential shame associated with reporting of symptoms. However, more research is needed in this area to definitively associate zolpidem with hyperprolactinemia and its related symptoms.

    Objectives:

    1. To investigate a possible mechanism for pharmacologically induced hyperprolactinemia.
    2. To explore possible mechanisms via which a commonly used treatment for insomnia, zolpidem, can lead to galactorrhea while considering how this can be directly applicable to the physician's patient population.
    3. To create awareness regarding a problem of underestimated prevalence due to the lack of externally visible symptoms.

    Relevance:
    As the use of non-benzodiazepines such as zolpidem continues to increase due to their more favorable adverse effect profile, the potential side effects must be further explored.

     
  14. Bipolar with Psychosis Secondary to Atripla: Case Report
    Presenting Author:  Stefani Parrisbalogun

    Background: Atripla is a combination medication for the treatment of HIV infection in adults and can be used alone as a complete treatment regimen or in combination with other anti-HIV medicines. It contains the following three anti-HIV medicines: efavirenz, emtricitabine, and tenofovir disoproxil fumarate. Atripla can cause serious psychiatric side effects including severe depression, suicide, paranoia, and mania. Although, the prevalence of these psychiatric side effects in patients using atripla is unknown or unreported.

    Objective: To describe the findings for and treatment of an 32 year old male with HIV and Bipolar with psychosis secondary to Atripla.

    Method: Case Report and Literature Review

    Results: The patient was continued on Atripla and treated with Haldol titrated to symptom alleviation. There is very few reported cases of bipolar with psychosis in HIV patients on Atripla in the literature.

    Conclusion: Patients with a known history or risk factors for bipolar or psychosis may need to be prophylactically started on antipsychotics prior to Atripla in addition to being closely monitored by psychiatry.

    References:

    1. Manning TG: Efavirenz and psychosis: is there a link? Aust N Z J Psychiatry 2012 Jul; 46(7):687-8

    2. DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents: "Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents, Department of Health and Human Services," February 12, 2013; 1-267. Available at http://www.aidsinfo.nih.gov

    Objectives:

    1. To describe the findings for and treatment of an 32 year old male with HIV and Bipolar with psychosis secondary to Atripla.
    2. To describe the psychiatric side effects associated with Atripla.
    3. To report the prevalence of psychiatric side effects as described in the literature.

    Relevance:
    To be aware and diligent in monitoring and treating psychiatric side effects of HIV medications during all stages of treatment.

     
  15. [T] Body Integrity Identity Disorder: A Case Report
    Presenting Author:  Rachna Raisinghani
    Co-Authors:  Christopher Helfer, Zeeshan Faruqui, James Levenson

    Background: Body integrity identity disorder is a rare condition, on the cusp of neurology and psychiatry, whose pathophysiology is undetermined. It is described in the literature under terms like "apotemnophilia" or "xenomelia". It raises perplexing ethical and clinical issues for surgeons and psychiatrists. We present a case of a 48 year old white male, who presented to our emergency department seeking amputation of both his lower extremities.

    Case: Mr. X presented to the ER after self-inflicted frost bite to both lower extremities, using ice followed by dry ice for over 10 hours, a method he had extensively researched over the Internet. He took several measures to avoid generalized hypothermia and other negative outcomes, and called for help only when he was certain that amputation would be medically necessary. He refused any attempts at salvaging his limbs, but was willing to consent to life-saving interventions, and of course amputation. Psychiatry got involved initially for assessing his capacity to consent for amputation, and later as part of the ethics committee convened to discuss his case. The question of capacity was a difficult one, and the psychiatrists who assessed him came to differing conclusions. We also obtained a detailed psychiatric history in an effort to learn more about this condition, the challenge being delineating his personal history from a narrative largely memorized from various sources on the Internet. He eventually underwent bilateral below-knee amputation and expressed satisfaction with the result.

    Discussion: Body integrity identity disorder is an extremely rare but fairly well circumscribed condition that has not yet found its way to diagnostic manuals. There are many theories proposed to explain its etiology, both psychological and neurobiological. The literature contains descriptive case reports and case series, but very little is known about psychiatric management. Free access and exchange of information on the internet makes it likely that we will end up seeing more patients like this in the future.

    Objectives:

    1. Apply knowledge of this rare condition in clinical practice, in teaching colleagues and trainees, and for further research.
    2. Appreciate the complex issues underlying capacity evaluation in such cases.
    3. Understand the implications of treating such patients for providers and institutions, and the potential medico-legal concerns that could arise.

    Relevance:
    This presentation will increase awareness of the challenges and complexities of this rare condition. C-L psychiatrists will hopefully feel better equipped to handle a similar case if they see one.

     
  16. [T] Psychotic Process, Due to an Unlikely General Medical Condition
    Presenting Author:  Waqar Rizvi
    Co-Authors:  Rajasekhar Kannali, Toni Love Johnson

    Background: Autoimmune polyendocrine syndrome, type 1 (APS-1) is a genetic disorder which presents with candidiasis, hypoparathyroidism, and Addison's Disease. It can also present with a range of nueropsychiatric manifestations, including depression, psychosis, confusion, and delirium. These manifestations usually disappear with correction of the respective electrolyte imbalances causing them. Less commonly is it associated with a new onset diagnosis of an actual psychotic process.

    Method: Case Report

    Results: We present the case of a 34 y/o man with no past psychiatric history and a past medical history of Addison's disease and hypoparathyroidism, admitted for Addison's crisis, (with hypotension, shakes, tremors, and generalized weakness). He was found to have significant electrolyte abnormalities, including hypocalcemia, hyponatremia, and hypochloremia. He was treated and maintained with low dose hydrocortisone, IV fluids and calcium gluconate, improving his electrolyte disturbances He began to exhibit symptoms of depression (due to recent news that his daughter also had similar medical complaints), and later delusion (grandiose, religious) and psychosis. He would walk around the unit, arms spread out, blessing individuals he passed, believing he was Jesus. He was noted to avoid eye contact, and seemed to be internally stimulated as well. A psychiatry consult was called given his new psychotic symptoms. Initially, it was presumed that these symptoms were due to the electrolyte imbalances, as in a delirium process. In addition to being given PRN medications of olanzapine and lorazepam, his underlying electrolyte imbalances had already been treated, aside from some residual hypocalcemia. The patient's psychiatric symptoms did not resolve with the normalization of the imbalances. Although his improving at times when receiving his PRN medications, his actual psychosis was not resolving. He was then put on quetiapine, scheduled. This further improved his symptoms, but without complete remission. He was discharged following complete resolution of his medical abnormalities, although still with some psychotic symptoms. When followed up, he was noted to still have symptoms of depression and hallucinations. Further questioning deduced that he had bouts of candidiasis during his childhood (persistent), followed by Addison's crisis and hypoparathyroidism. He was diagnosed with schizoaffective disorder in addition to APS-1.

    Conclusion: Numerous medical conditions can lead to a variety of neuropsychiatric symptoms. Usually, these resolve when the underlying cause is treated. However, a full blown psychiatric ailment can come about, requiring further ongoing psychiatric treatment, even when the underlying imbalances are treated. APS-1 can cause neuropsychiatric symptoms, due to several possible electrolyte imbalances. A full workup is necessary as to rule in (or out) any psychiatric diagnosis.

    References:

    1. Drake FR: Neuropsychiatric-like symptomatology of Addison's disease. Am J Med Sci 1957 Jul; 234(1):106-13.

    2. Cohen SI, Marks IM: Prolonged organic psychosis with recovery in Addison's disease. J Neurol Neurosurg Psychiatry 1961 Nov; 24:366-8.

    Objectives:

    1. Understand the importance of a full psychiatric evaluation and work up.
    2. Understand that not all psychiatric complaints would be due to an underlying imbalances.
    3. Better establish the relationship between APS-1 and a comorbid psychotic process.

    Relevance:
    A full psychiatric evaluation and follow-up is always necessary, even if a delirious-like process is suspected, with a predicted quick resolution of symptoms following treatment of underlying electrolyte imbalances.

     
  17. Quick Resolution of High Lethality Suicidal Behavior and Depression After Administration of Single Low Dose Ketamine I.V. Push
    Presenting Author:  Ricardo Salazar
    Co-Author:  Sabitha Aligeti

    Objective: Intravenous ketamine administration can be used to abort acute depressive symptoms and suicidality in severely depressed patients within hours as compared with traditional antidepressants. This single-case trial was conducted to improve depressive and suicidal symptoms in an emergent condition that required urgent intervention.

    Methods: In an open label trial, a 32-year-old male with untreated history of first episode of severe major depressive disorder and co-occurring alcohol dependence, received a single intravenous push of ketamine (0.5 mg/kg) and rated at baseline and at 2, 24, 48 and 120 hours post-administration with the 7-item Hamilton Depression Rating Scale (HDRS), and the Montgomery-Asberg Depression Rating Scale (MADRS) by the same interviewer. Subject was followed during 21 days of hospitalization, and then as an outpatient at the Mood and Anxiety Clinic at the University of Texas Health Science Center San Antonio for the subsequent six months.

    Results: Single intravenous push of ketamine improved symptoms of suicidal ideation and depression within 2 hours of ketamine administration (HDRS, MADRS). Positive effects continued with resolution of depression and suicidality at subsequent interval points (24, 48, and 120 hours). The addition of SSRI during recovery phase (day 4), followed by switch to a mood stabilizer (lithium carbonate) as outpatient after day 21, having elicited a prior history of hypomania and establishing a final diagnosis of bipolar II disorder. He continues in full remission and has returned to work as documented at six month follow-up visit.

    Conclusions: In this subject with co-occurring alcohol dependence, the single administration of ketamine produced positive results with no further ketamine administration, supporting the role of this medication in relieving symptoms of major depression. Further clinical trials are needed to investigate these beneficial effects of low dose ketamine in depressed patients in acute emergency settings.


    References:

    1. Autry, et al: NMDA receptor blockade at rest triggers rapid behavioral antidepressant responses. Nature 475:91-95.

    2. aan het Rot M, Collins KA, Murrough JW, et al: Safety and efficacy of repeated-dose intravenous ketamine for treatment-resistant depression. Biol Psychiatry 2010 Jan 15; 67(2):139-45. doi: 10.1016/j.biopsych.2009.08.038.

    3. Berman RM, Cappiello A, Anand A, et al: Antidepressant effects of ketamine in depressed patients. Biol Psychiatry 2000 Feb 15; 47(4):351-4.

    4. DiazGranados N, Ibrahim LA, Brutsche NE, et al. Rapid resolution of suicidal ideation after a single infusion of an N-methyl-D-aspartate antagonist in patients with treatment-resistant major depressive disorder. J Clin Psychiatry 2010 Dec; 71(12):1605-11. doi: 10.4088/JCP.09m05327blu. Epub 2010 Jul 13.

    5. Larkin GL, Beautrais AL, Turelli RR, et al: A preliminary naturalistic study of low-dose ketamine for depression and suicide ideation in the emergency department (Citations: 3), Eur Psychiatry 2011; 26:1607.

    Objectives:

    1. To investigate ketamine IV as fast acting antidepressant.
    2. Clinical applicability of ketamine IV push in emergency setting.
    3. Need for more clinical trials on ketamine IV push due to limited randomized control trials to date.

    Relevance:
    So far currently available antidepressants take few weeks for their antidepressant action, and their role is very limited in emergency/life threatening situations. Ketamine administration can be choice in these situations.

     
  18. [T] Folie à deux on the Consultation-Liaison Psychiatry Service: Who’s Fooling Who?
    Presenting Author:  Rita Schlanger
    Co-Authors:  Rita Schlanger, Karen Salerno, Margo Funk

    Objective: Shared delusional disorder is a rare psychiatric condition characterized by the transference of a delusion from a primary person to a secondary in the context of a close relationship.

    Case Presentation: We present the case of a 69 y/o homeless, married, Iranian female who presented to the ED with chest pain, hypertensive urgency, and found to have ischemic changes for which she refused intervention. With her husband by her side and throughout her hospital course, she was fixated on an "embezzlement situation" that led to the foreclosure of their home and loss of her business. Evaluation by social work revealed unwillingness to accept any aid for housing, medications, or transportation. She stated that she was "too educated for public assistance." Psychiatry was consulted regarding possible delusions.

    Results: Psychiatric evaluation revealed an articulate and well-groomed married couple who contributed equally to the history. They had been living at separate men's and women's homeless shelters for the past 6 years. The couple was tangential and unable to provide explicit facts regarding the embezzlement of their company, circuitously noting FBI involvement and deceit by lawyers. They were not willing to describe the circumstances leading to their homelessness of six years, but shared a marked distrust of the "system." For the past several years, they spent every day at the library researching similar cases of fraudulence to garner support and make a plea to the government for justice. Notably, the patient authored patents on a variety of scientific inventions and provided a binder of legal documents to support this. Her husband was confirmed to be a former NASA employee and PhD with numerous scientific publications in the field of physics.

    Conclusions: Although the couple had numerous verified achievements, their common overvalued ideas and perseveration on being persecuted suggested a diagnosis of shared delusional disorder. The diagnosis of folie à deux is difficult to make, often because the pair lives in relative isolation and/or because only one person presents for evaluation. A multidisciplinary approach with multiple sources of collateral is useful. Ideally, separation may help with diagnosis and treatment; however, this may not be realistic, especially when there is little other psychosocial support. As in this case, the condition may prevent access to and acceptance of necessary medical care.

    References:

    1. Christensen RC, Ramos E: The social and treatment consequences of a shared delusional disorder in a homeless family. Innov Clin Neurosci 2011; 8(4):42-44.

    2. Newman WJ, Harbit MA: Folie a deux and the courts. J Am Acad Psychiatry Law 2010; 38:369-375.

    3. Mentjox R, van Houten CA, Kooiman CG: Induced psychotic disorder: clinical aspects, theoretical considerations, and some guidelines for treatment. Compr Psychiatry 1993; 34(2):120-126.

    Objectives:

    1. Identify common features of shared delusional disorder (folie a deux) as they present on the consultation-liaison psychiatry service.
    2. Identify strategies for helping a patient obtain optimal healthcare services in the setting of a shared delusional disorder.
    3. Coordinate a multidisciplinary approach, including social work, case management and other medical teams, when working with a patient with shared delusional disorder.

    Relevance:
    Shared delusional disorder is a condition which may go unrecognized in the acute hospital setting, yet may significantly impede medical care.

     
  19. [T] Catatonia in Resource Limited Settings: A Case Series of Four Patients
    Presenting Author:  Stephanie Smith
    Co-Authors:  David Grelotti, Eugenie Uwimana, Jean-Sauveur Ndikubwimana, Dominiq Dushimiyimana, Clemence Uwamariya, Robert Bienvenu, Giuseppe Raviola, Gregory Fricchione

    Background/Purpose: The catatonic syndrome (“catatonia”) is a movement and motivation dysregulation syndrome linked with multiple neuropsychiatric and medical disorders [1]. The prevalence of catatonia in international prospective studies is estimated to be between 8 and 18% of hospitalized psychiatric patients [2]. Although the signs of catatonia were described as a single independent disorder well over one hundred years ago [3], underrecognition of catatonia as a disorder of motor signs remains an obstacle to effective treatment worldwide, especially given the pervasive nosologic error linking schizophrenia and catatonia. One study suggests that only 11% of patients with catatonia are correctly identified by specialists [4]. Diagnostic uncertainty may be magnified in rural, resource-limited general health clinic settings where the majority of care is provided by non-mental health professionals. However, catatonia is both recognizable and readily treatable in these settings. We describe four patients in Haiti and Rwanda in whom explicit recognition and treatment of catatonia with benzodiazepines were associated with complete symptom resolution and return to baseline functioning level. A protocol for identifying and treating catatonia in resource limited settings is proposed.

    Methods: We describes four cases of catatonia responding to treatment with either lorazepam or diazepam in rural Haiti and Rwanda.

    Results: The four patients in this report exhibited a range of characteristic and recognizable signs of catatonia, including immobility/stupor, stereotypic movements, echophenomena, posturing, odd mannerisms, mutism, and refusal to eat or drink. All four cases presented initially to rural outpatient general health services in low resource settings, after which a more specialized mental health service was consulted. In some cases, diagnostic uncertainty initially led to treatment with typical antipsychotics. In each case, proper identification and treatment of catatonia with benzodiazepines led to significant clinical improvement.

    Conclusion: Familiarity with the clinical features of catatonia is essential for health professionals working in low resource settings. Although under-recognition or diagnostic uncertainty may present barriers to treatment, catatonia can be effectively and cheaply treated in these settings. Consultation-liaison psychiatrists can play a critical role in expanding the capacity of local providers to accurately recognize this treatable disorder.

    References

    1. Gelenberg A: The Catatonic Syndrome. Lancet 1976; 1:1339–41.

    2. Seethalakshmi R, Dhavale S, Suggu K, Dewan M: Catatonic syndrome: importance of detection and treatment with lorazepam. Ann Clin Psychiatry 2008 Jan-Mar; 20(1):5-8.

    3. Kahlbaum KL: Catatonia. Translated by Levi Y, Pridon T. Baltimore, MD, Johns Hopkins University Press, 1973.

    4. van der Heijden FM, Tuinier S, Arts NJ, Hoogendoorn ML, Kahn RS, Verhoeven WM: Catatonia: disappeared or under-diagnosed? Psychopathology 2005; 38:3-8.

    Objectives:

    1. To add to the limited literature on catatonia in low resource settings.
    2. To demonstrate that explicit recognition and treatment of patients with catatonia in resource limited settings can stimulate complete symptom resolution and return to, or improvement in, baseline functioning level.
    3. To articulate a clinical protocol to treat catatonia in low resource settings, for use by clinicians and health workers with limited training in neuropsychiatry.

    Relevance:
    Consultation-liaison psychiatrists can play a critical role in expanding the capacity of providers in resource limited settings to recognize and treat catatonia.

     
  20. [T] Psychosis and Mood Changes Due to Adipex (Phentermine) Use: Case Report and Literature Review
    Presenting Author:  Samidha Tripathi
    Co-Author:  Carolina Retamero

    Introduction:Phentermine is an appetite suppressant with a molecular structure similar to amphetamine that has been associated with acute onset psychosis and mood changes.We describe the case of a patient who presented with an acute psychotic break probably secondary to chronic phentermine use.

    Case description: A 35 year old Caucasian female with a past psychiatric history of post partum depression presented to the emergency room (ER) in a somnolent state.She reported auditory and vivid visual hallucinations, persecutory ideas towards her boy friend, insomnia and intermittent confusion for the last week. Her speech was pressured, fast, difficult to comprehend at times, and her affect was labile and irritable. A urine drug screen was positive for amphetamines. She reported using diet pills Adipex (phentermine) once daily since the age of 16. She had discontinued the drug abruptly for one month only to resume it at a higher dose 1 week prior to presentation, initially for weight loss and later also for recreational purposes. Her symptoms remitted after a few days in the inpatient unit, which coincided with the natural elimination of the drug from her body.

    Discussion:A PubMed search using "phentermine and psychosis" generated 13 results with 6 case reports for phentermine. Five of these were more than four decades old with only one recent article (2011). The patients in the reports developed psychotic or manic features after both chronic and acute phentermine use mainly for weight reduction. A more recent article by Alexander et al., mentioned 4 patients who were abusing diet pills for recreational purposes ("for lethargy"). In all 4 cases, phentermine either precipitated the original pathology (mania in BPAD and depression in postpartum depression and substance abuse) or brought about an underlying illness.

    Phentermine acts through sympathomimetic pathways and releases serotonin and dopamine. Additionally, phentermine has the potential to cause psychological dependence and tolerance.

    References:

    1. Alexander J, Cheng Y, Choudhary J, Dinesh A: Phentermine (Duromine) precipitated psychosis. The Royal Australian and New Zealand College of Psychiatrists 2011; 685-686.

    2. Devan GS: Phentermine and psychosis. British Journal of Psychiatry 1990; 156:442-443.

    3. Hoffman BF: Diet pill psychosis. CMA Journal 1977; 116:351, 354-355.

    4. Hoffman BF: Diet pill psychosis: follow up after 6 years. CMA Journal 1983; 129:1077-1078.

    5. Lee SH, Liu CY, Yang YY: Schizophrenia-like psychotic disorder induced by phentermine: a case report. Zhonghua Yi Xue Za Zhi (Taipei) 1998; 61(1):44-7.

    6. Rubin RT: Acute psychotic reaction following ingestion of phentermine. Am J Psychiatry 1964; 120:1124-5.

    Objectives:

    1. To understand the changing trends in diet pill use: from weight loss to recreational drug use.
    2. To discuss the psychiatric adverse effects of phentermine use.
    3. To discuss the need for tighter regulation of its distribution under the controlled substances act.

    Relevance:
    The importance of tighter regulation of OTC stimulant analogs and awareness about early detection and treatment of reversible psychotic/mood symptoms secondary to what may be "harmless weight loss and energy pills."

     
  21. [T] Catatonia? Conversion Disorder? A Case of Cerebral Fat Emboli
    Presenting Author:  Barbara Wilson
    Co-Author:  Julia Frew

    Fat emboli syndrome (FES) is a rare constellation of symptoms that may follow long bone trauma or orthopedic procedures. The classic triad of symptoms is respiratory compromise, altered mental status, and a petechial rash developing from the distribution of fat emboli in the respiratory circulation. In order for fat emboli to reach the brain, a cardiac (e.g., patent foramen ovale) or arterio-pulmonary shunt is required. Cerebral fat emboli often are undetected on computed tomography (CT) but display a classic “starfield pattern” on MRI. Cerebral fat embolism (CFE) is a neurologic consequence of traumatic injury or orthopedic surgery that may occur in the absence of FES. Typically a patient will present with a lucid interval lasting several hours to days after the event followed by a rapid decline in mental status that most frequently resolves over weeks to months as cerebral insult abates. Treatment is supportive and requires periodic neurologic reexamination to assess improvement. As psychiatrists are often consulted to assess altered mental status postoperatively and post-suicide attempt, we present a case of CFE following a suicide attempt resulting in upper extremity long bone trauma.

    Objectives:

    1. Recognize the common signs of fat emboli syndrome and cerebral fat emboli.
    2. Communicate prognosis and tempo of recovery to treatment teams and families.
    3. Quickly create alternative psychiatric diagnoses that may present like cerebral fat emboli.

    Relevance:
    Psychiatrists are often asked to assess unusual behaviors in post-operative or post-trauma patients with preexisting psychiatric diagnoses. It is important to be able to recognize CFI quickly for proper treatment.

     

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Section C:  Delirium

  1. [T] Zany on Zannie: Delirium Induced by a Benzodiazepine Marketed as Air Freshener
    Presenting Author:  Ashhar Ali
    Co-Authors:  Jason Jerry, Elias Khawam

    Purpose: Phenazepam is the latest example of a substance of abuse that is not a controlled substance and is marketed over the counter as a household product labeled “not for human consumption” in an attempt to avoid scrutiny by legal authorities. Such drugs of abuse have been termed synthetic legal intoxicating drugs or “SLIDS” [1]. Federal and state legislation has targeted the two largest groups of drugs that fall under this classification—“bath salts” (synthetic cathinones) and “spice” (synthetic cannabinoids). New drugs, such as phenazepam, seem to be gaining popularity in the wake of this legislation. We present this case to educate physicians about the clinical presentation and management of a patient intoxicated with phenazepam. We will also review other SLIDS intoxication syndromes.

    Methods: We report a case of a 19 year old Russian-American male who presented to the emergency room with confusion after injesting a bottle of “Zannie Air Freshener" spray. He was brought to the emergency department by his parents who found him minimally responsive, confused, and hallucinating. He experienced significant impairment in memory, concentration, attention, and delayed verbal responses. He was admitted to medicine unit and treated with lorazepam and haloperidol.

    Results: Zannie Air Freshener contains a benzodiazepine, phenazepam, which is produced in Russia and not listed as a controlled substance in the U.S. Our patient had purchased the product over the counter at a local “head shop,” and had inhaled its contents in an attempt to get high. Our patient’s confusion resolved within 48 hours of admission.

    Conclusions: Phenazepam intoxication should be considered in the differential diagnosis of any patient with a history of substance abuse who presents with the acute onset of hallucinations and cognitive impairment. Such presentations in otherwise healthy individuals who have no previous history of a psychotic disorder should prompt the taking of a detailed history of novel drugs of abuse. Patients thought to be suffering from phenazepam should be hospitalized with close monitoring for respiratory compromise until their mental status clears.

    References:

    1. Jerry JM, Collins GB, Streem D: Synthetic legal intoxicating drugs: a review of the emerging “incense” and “bath salt” phenomenon. Cleve Clin J Med 2012; 79(4):258-264.

    2. Dargan PI, et al: First reported case in the UK of acute prolonged neuropsychiatric toxicity associated with analytically confirmed recreational use of phenazepam. Eur J Clin Pharmacol 2013; 69:361-363.

    3. Corkery JM, Schifano F, Ghodse AH: Phenazepam abuse in the UK: an emerging problem causing serious adverse health problems, including death. Hum. Psychopharmacol Clin Exp 2012; 27:254–261.

    4. Maskell PD et al. Phenazepam: The drug that came in from the cold. Journal of Forensic and Legal Medicine 19 (2012) 122-25.

    Objectives:

    1. To familiarize consultation liaison psychiatrists with a new class of SLIDS comprised of benzodiazepines.
    2. To educate consultation-liaison psychiatrists about the typical presentation and management of a phenazepam-intoxicated patient.
    3. To discuss the appropriate screening and management of intoxicated patients with suspected use of synthetic legal intoxicating drugs.

    Relevance:
    The emergence of novel SLID-type agents is contributing to an increase in ER presentations for intoxication syndromes. Consultation-liaison psychiatrists should consider novel SLID intoxication syndromes in their differential diagnoses.

     
  2. [T] Rates of Delirium of Patients with Psychiatric Illness: A Retrospective Review of Psychiatric Consults from 2010 to 2012
    Presenting Author:  Kang Won Choi
    Co-Authors:  Hoyle Leigh, Ronna Mallios

    Purpose: The purpose of this study was to compare rates of delirium of categories of psychiatric diagnoses.

    Methods: We reviewed records from the consult-liaison database of psychiatric consults at Community Regional Medical Center, a 626-bed hospital, for a 3-year period (08/2010 to 08/2012). 2,495 psychiatric consults were recorded during this period. Consults were grouped into major diagnostic categories (mood disorders, psychotic disorders, anxiety disorders, substance disorders, and cognitive disorders). Disorders that did not fall into these categories were excluded, as were consults with no clear psychiatric diagnosis. Rates of delirium within each category were calculated. A chi-square analysis (2x2 contingency table) was used to determine statistical differences. The research protocol received IRB approval.

    Results: Out of 1782 consults included in the study, 1086 (60.9%) had mood disorders, 356 (19.9%) had psychotic disorders, 133 (7.5%) had anxiety disorders, 113 (6.3%) had cognitive disorders, and 94 (5.3%) had substance-related disorders. Rates of delirium were determined: cognitive disorders 28.3%, psychotic disorders 28.3%, mood disorders 11.0%, substance disorders 15.9%, and anxiety disorders 5.3%. Comparing rates of delirium of cognitive disorders and psychotic disorders, there was no statistical difference (χ2, p = 0.991). Comparing rates of delirium of psychotic disorders with the other disorders (excluding cognitive disorders), there was statistical significance (χ2, p=0.0001). Schizophrenics had the highest rate of delirium, 41.03%.

    Conclusions: Delirium is believed to increase mortality [1]. Also known is that mental illness (schizophrenia) may shorten lifespan [2]. A recent study at the Portland VA, examining schizophrenics admitted from 2004 to 2009, noted that 37% were diagnosed with delirium [3]. In this study, 41% of admitted schizophrenics had delirium. Interestingly, comparing diagnostic groups, both cognitive and psychotic disorders had the same (as well as highest) rates of delirium, 28.3% (χ2, p=0.991). Although it is accepted that schizophrenics experience symptoms that remain largely stable over time, and may even show some improvement [4], an increased susceptibility to delirium may suggest a neurodegenerative process. A “stress model” of delirium [5] may help to explain potentially higher rates of delirium in patients with psychotic disorders.

    References:

    1. Kiely DK: Persistent delirium predicts increased mortality. J Am Geriatr Soc 2009 January; 57(1):55-61.

    2. Hennekens CH: Increasing global burden of cardiovascular disease in general populations and patients with schizophrenia. J Clin Psychiatry 2007; 68(Suppl 4):4-7.

    3. Ganzini L, et al: Delirium and decisional incapacity in veterans with schizophrenia and medical illness. Gen Hosp Psychiatry 2012; 34:506-509.

    4. Rund BR: Review of longitudinal studies of cognitive functions in schizophrenia patients. Schizophr Bull 1998; 24(3):425-435.

    5. MacLullich AMJ, et al: Unraveling the pathophysiology of delirium: a focus on the role of aberrant stress response. J Psychosom Res 2008; 65:229-238.

    Objectives:

    1. Understand that delirium increases mortality.
    2. Understand that people with mental illness have shorter lifespans.
    3. Consider that people with psychotic disorders may have greater susceptibility to delirium.

    Relevance:
    Is schizophrenia a neurodevelopmental or neurodegenerative disorder or both? Higher susceptibility to delirium suggests some neurologic vulnerability.

     
  3. [T] An Irreversible Delirum: Pushing the Envelope for Goals of Care Within the Islamic Bioethical Framework
    Presenting Author:  Sonia Demetrios
    Co-Authors:  Waqar Rizvi, Mallika lavakumar

    Background: In Islam, the body is conceptualized as a vehicle to do God's work and expediting death is considered a sin againist God. This basic tenet of the religious lives of Muslims, a growing demographic group in the United States, impacts goals of care during the end-of-life. There is consensus among Islamic bioethicists that cessation of the heartbeat and brain death substantiate discontinuation of life-preserving treatment given eventual futility of medical interventions [3]. There is no published literature on the role of a terminal delirum in developing goals of care that are consistent with the Islamic bioethical framework.

    Method: Case Report

    Result: We report a case of a 57 y/o Muslim man who was ambulated to a nearby Midwestern academic county hospital after being stabbed three times in the abdomen. An exploratory laparotomy initially stabilized him with eventual clinical deterioration over the next 3 months. He developed irreversible pulmonary, renal and hepatic failure, requiring mechanical ventilation and hemodialysis. The primary surgical team and all consultants were of the opinion that his medical problems could not be reversed. The patient was in an irreversible hypoactive delirium and during a brief period of lucidity he asked to go home and die. The family was initially averse to honoring this due to their religious leanings and believed that as long as his heart was beating and he was not officially brain dead he should be kept alive. The psychiatry consult service was asked to comment on whether the patient had the capacity to make the decision to discontinue life-saving treatment. Rather than respond to this consultation question, which would have narrowed the scope of involvement and would have limited assistance in this challenging case, the psychiatric consultant recommended a family meeting to address fantasies and misperceptions regarding prognosis and to provide an avenue to express their religious concerns and their sense of personal loss. A turning point in the meeting was clarification that the patient was in a state of irreversible delirium, described to the family as a "permanent curtain over the brain." A decision was made by the family to discontinue hemodialysis and to not resuscitate the patient. The patient died a peaceful death the following day.

    Conclusion: An irreversible delirium might be conceptualized as a form of permanent brain dysfunction. The same Islamic bioethical principles that support discontinuation of life-preserving treatment in the context of brain death migt apply in the case of a permanent delirium where medical prognosis is poor. This consideration might assist Muslim patients, their families, and their medical providers in formulating goals of care when interventions seem futile.

    References:

    1. Johnson M: End of life care in ethnic minorities. BMJ 2009; 338:489-490.

    2. Padela AI: Islamic medical ethics: a primer. Bioethics 2007; 21(3):169-78.

    3. Sachedina A: End-of-life: the Islamic view. Lancet 2005; 366:774-9.

    Objectives:

    1. To be aware of basic principles of Islamic bioethics as they pertain to end-of-life care.
    2. To appreciate that religious leanings play a role in discontinuation of life-preserving treatment.
    3. To learn how to facilitate inclusion of religious beliefs in the discussion of end-of-life care for patients.

    Relevance:
    This presentation is of relevance to all those involved in end-of-life care of ethnic minorities.

     
  4. WITHDRAWN
     
  5. [T] Chronobiology in Delirium and Critical Illness: The Role of Chronotherapeutics in Psychosomatic Medicine
    Presenting Author:  Mark Oldham
    Co-Author:  Paul Desan

    Purpose: Our goal is to investigate the state of the literature with respect to chronobiology and chronotherapeutics in delirium and the critically ill.

    Methods: We conducted a Medline search for clinical trials cross-referencing terms related to chronobiology and chronotherapeutics (“chronobiol*,” “chronotherap*,” “chronodisrupt*,” “circadian,” “diurnal,” “nocturnal,” “sleep fragment*,” “sleep wake,” “light therapy,” “dark therapy,” “sleep deprivation,” “wake therapy,” “sleep phase advance,” and “melaton*”) with terms related to delirium or critical illness (“delirium,” “encephalopath*,” “altered mental status,” “critical* ill*,” “critical care,” and “ICU”). The results were reviewed for relevant articles addressing chronobiological application among patients with delirium and critical illness. Additional articles were identified upon review of the references in these studies.

    Results: Forty-one relevant studies were identified. Seventeen of these describe various disruptions of circadian sleep/wake patterns and diurnal variations in serological values (Boyko 2012); in sum, they implicate circadian dysregulation in the pathophysiology of delirium (Weinhouse 2009). Six investigate the association between light and delirium. Of these, bright light as monotherapy (Ono 2011; Taguchi 2007) and as an adjunct to risperidone (Yang 2012) was shown to improve the clinical course of delirium. Three articles explore the role of melatonin agonism in delirium. Among these three, melatonin decreased the incidence of delirium (Al-Aama 2011), and ramelteon hastened delirium resolution in a case series (Furuya 2012). Fourteen investigate the role of different pharmacological and non-pharmacological interventions to normalize sleep/wake patterns in the critically ill; in fact, in addition to improving sleep, earplugs at night have also been shown to prevent delirium (Mills 2012).

    Conclusions: A growing body of evidence continues to explore the integral role of chronobiological disruption in the critically ill and those with delirium. Delirium may be appreciated as a model for chronodisruption, which provides a rationale for chronotherapeutic interventions both for its prevention and resolution. A consistent literature documents circadian dysregulation among the critically ill and delirious, and preliminary evidence supports the role of chronotherapeutic interventions such as melatonin agonists, bright light therapy, and circadian rhythm stabilization in critically ill and delirious patients. Such interventions carry limited risk and minimal cost. We expect that large-scale, randomized trials would likely prove illuminating in defining the role of the emerging field of chronotherapeutics for the delirious and critically ill.

    References:

    1. Al-Aama. Int J Geriatr Psychiatry 2011; 26(7):687-94.

    2. Boyko. Acta Anaesthesiol Scand 2012; 56(8):950-8.

    3. Furuya. Psychogeriatrics 2012; 12(4):259-62.

    4. Mills. Crit Care 2012; 16(4):139.

    5. Ono. Intensive Crit Care Nurs 2011; 27(3):158-66.

    6. Taguchi. Intensive Crit Care Nurs 2007; 23(5):289-97.

    7. Weinhouse. Crit Care 2009; 13(6):234.

    8. Yang. Gen Hosp Psychiatry 2012; 34(5):546-51.

    Objectives:

    1. Articulate the state of the literature regarding the chronobological disruption in delirium and critical illness.
    2. Weigh the potential risks and benefits of chronotherapeutic interventions in the management of those with delirium or critical illness.
    3. Consider modifying current practice in the clinical management of those with delirium or critical illness to incorporate chronotherapeutic interventions.

    Relevance:
    Delirium represents a model of chronbiological dysregulation, and chronotherapeutic techniques have been shown to improve clinical course of those with delirium and critical illness.

     
  6. [T] Citation Classics in Delirium
    Presenting Author:  Adam Pendleton
    Co-Author: Jason Caplan

    Background: High impact studies in any field of medicine will receive large numbers of citations. We identified the top cited works on the subject of delirium.

    Methods: A Web of Science search was performed using the keyword "delirium*" in the title of the work (the asterisk was included in the search string as a wild card character). We considered articles with more than 200 citations to be a "citation classic" consistent with guidelines established by similar reviews in other fields

    Results: The 25 identified classic articles appeared in 12 different journals, with the majority appearing in the Journal of the American Medical Association, Journal of the American Geriatric Society, and the New England Journal of Medicine. Of the citation classics, there were 6 on assessment or screening methods, 8 on delirium as a predictive or prognostic factor, 10 on delirium in the elderly population, 2 on prevention of delirium, 2 on prospective studies, and 1 each on symptom rating scales, clinical description, and psychopharmacological treatment of delirium.

    Conclusions: The identification of articles with high numbers of citations can highlight the history of research on a particular subject and help direct future inquiry.

    Objectives:

    1. Utilize online publication databases to find articles which have had the greatest citation impact.
    2. Explore information available on highly cited articles to understand which areas of a subject have and have not produced high citation impact studies.
    3. Analyze data available on highly cited articles to develop a strategy on which journals might be appropriate targets for submission of future publications.

    Relevance:
    Highlighting areas of research in delirium which have had high citation impact will illustrate which areas still need investigation and potential publication destinations for such studies.

     
  7. Delirium: A Cross-Sectional Study Examining Prediction, Identification, and Symptom Severity in Surgical Patients
    Presenting Author:  Carole Richford
    Co-Authors:  Peggy Simpson, Stephen Fitzpatrick, Maria Corral, Julia Raudzus, Grant Millar

    Delirium is a neurobehavioral syndrome caused by transient disruption of normal neuronal activity secondary to systemic disturbances. The incidence of postoperative delirium in people undergoing surgical procedures ranges from 9% to 87% depending on several factors including the patient population and the degree of operative stress. The development of postoperative delirium has significant effects on length of hospitalization, cost of care, complications, morbidity, mortality, and long term cognitive impairment. Even when delirium is addressed, there are inconsistencies in preventative strategies, method of identification, diagnostic definition, perceived cardinal symptoms, and threshold of duration or severity that triggers pharmacological interventions.

    Purpose: Investigate the gap in current practices in a large acute care surgical center by benchmarking care with an evidence based clinical pathway designed to predict, identify and manage post operative delirium.

    Method: A cross-sectional prospective observation study was conducted with a population of individuals admitted to St. Paul’s Hospital for large bowel, vascular, orthopedic and cardiac surgery. Patients were over age 55 and able to give informed consent (N=250).

    Variables and Methods of Assessment: Preoperative assessment included demographic and medical information, history of alcohol and other substance use and blood chemistry as well as depression (Geriatric Depression Scale) cognition (Montreal Cognitive Assessment) and functional capacity (IADL). Postoperative assessment included screening for symptoms of delirium every 12 hours using the CAM. For those screening positive a diagnostic assessment was made by a psychiatrist using DSM-IV diagnostic criteria and the Delirium Rating Scale (DRS-R-98). Symptom severity was tracked daily until the episode resolved. Prior to discharge the participant was assessed for function and cognition.

    Pharmacological and non pharmacological interventions for delirium were tracked.

    Results: Outcome measures include changes in cognitive status (MoCA), changes in functional status (IADL), length of stay, severity of delirious episode (DRS-98), efficacy of pharmacological intervention including the number of days the patient is classified as delirious, complications and mortality.

    Conclusion: Delirium has a high incidence in surgical patients. Implementing an evidence-based clinical pathway to predict, identify, and manage delirium in surgical patients improves interdisciplinary clinical practices and has a significant impact on patient outcomes.

    References:

    1. Rudolph JL, Jones RN, Levkoff SE, et al: Derivation and validation of a preoperative prediction rule for delirium after cardiac surgery. Circulation 2009; 119:229-236.

    2. Shim JJ, Leung JM: An update on delirium in the postoperative setting: prevention, diagnosis and management. Best Practice Research Clinical Anesthesiology 2012; 26(3):327-43.

    3. Smith PJ, Atix DK, Weldon BC, Greene N, Monk T: Executive function and depression as independent risk factors for post operative delirium. Anesthesiology 2009; 110(4):781-787.

    4. Maldonado J: Delirium in the acute care setting: characteristics, diagnosis and treatment. Critical Care Clinics 2008; 24:657-722.

    Objectives:

    1. To compare patient factors that predicts delirium in large bowel, vascular, orthopedic, and cardiac surgery.
    2. To describe the severity and duration of delirium symptoms in individuals undergoing large bowel, vascular, orthopedic, and cardiac surgery.
    3. To identify cognitive and functional changes resulting from delirium in individuals undergoing large bowel, vascular, orthopedic, and cardiac surgery.

    Relevance:
    This presentation is relevant to consultation-liaison psychiatrists, general surgeons, critical care teams, and nurses dealing with postoperative surgical patients

     
  8. Prevention, Identification, and Nursing Management of Delirium: A Knowledge Translation Project
    Presenting Author:  Peggy Simpson
    Co-Authors:  Carole Richford, Stephen Parker

    Delirium in surgical patients is under-recognized, under-reported and under-treated. Nurses are most often involved with 24-hour postoperative patient assessments and can be the first to identify delirium and initiate a psychiatric referral. Nurses need knowledge and skill to both identify delirium and engage in non-pharmacological interventions to address risk factors to prevent delirium or reduce the severity of delirium. Unfortunately, evidence suggests nurses may miss key symptoms of delirium and perform superficial mental status assessments. Nurses also differ in their knowledge of delirium, recognition of delirium, assessment and documentation of delirium.

    Purpose: Monitor the uptake of knowledge by surgical nurses of how they identify, prevent, and manage delirium in surgical patients, to determine the impact on the surgical patient population, and to identify successful sustainment strategies in the use of knowledge related to delirium.

    Method: Participatory Action Research: Surgical nurses (N=40) participated in an educational session and in follow-up appreciative inquiry sessions. The process involved a spiral of self reflecting cycles and included: planning a change, acting and observing the process and consequences of change, reflecting on these processes and consequences, re-planning, acting and observing again.

    Results: Pre-post test questionnaires measured changes in nurses’ knowledge of delirium. Knowledge use was measured by text analysis of the inquiry sessions, chart audit using the Prevention, Identification and Nursing Management of Delirium Project Data Collection Tool {PINMD including CAM). Surgical patient outcome indicators included global data from the administrative and clinical hospital data bases about differences in the incidence of delirium, mortality, length of stay, number of falls.

    Conclusion: Sustainable changes to evidence-based nursing practice for prevention, identification and management of delirium make a significant difference in health outcomes for people at risk or who have developed postoperative delirium.

    References:

    1. Agar M, Draper B, Phillips P, Phillips J, Collier A, Harlum J, Currow, D: Making decisions about delirium: a qualitative comparison of decision making between nurses working in palliative care, aged care, aged care psychiatry and oncology. Palliative Medicine 2012; 26(7):887-96.

    2. Swan B, Becker J, Brawer R, Sciamanna C: Factors influencing the implementation of a point of care screening tool for delirium. MedSurg Nursing 2011; 20(6):318-22.

    3. Graham I, Logan J, Harrison M, Straus S, Tetroe J, Caswell W, Robinson N: Lost in Translation: Time for a map? The Journal of Continuing Education in the Health Professions, 2006; 26(1):13-24.

    4. Steis M, Fick D: Are nurses recognizing delirium? A systematic review. Journal of Gerontological Nursing 2008; 34(9):40-48.

    Objectives:

    1. To identify factors that facilitate surgical nurses using evidence-based guidelines for prevention, identification, and management of delirium.
    2. To compare the incidence of delirium, number of falls, mortality, length of stay before and after a knowledge translation project.
    3. To describe nurses’ perceptions of the most effective strategies to sustain evidence-based clinical practice for prevention, identification, and management of delirium.

    Relevance:
    Knowledge translation can close a major gap in the research evidence and the way nurses and other interdisciplinary team members predict, identify, and manage delirium.

     
  9. [T] Delirium in General Surgery Patients: A Systematic Review of Predictors, Prevention, and Treatment
    Presenting Author:  Mohit Singh
    Co-Authors:  Carole Richford, Peggy Simpson

    Background: While a growing body of knowledge related to delirium in hospitalized patients exists, there are fewer studies that focus specifically on the general surgery population. The number of older people undergoing general surgical procedures is expected to rise. Current evidence suggests both a prevalence of delirium up to 51% and increased risks for delirium following procedures carried out by general surgeons.

    Data Sources: A systematic review of English and non-English articles using MEDLINE, EMBASE, PubMed, and the Cochrane Database from years 1995-2013. Key search terms included delirium, abdominal surgery, digestive tract procedures, prevention, and pharmacologic therapy.

    Study Selection: Prospective and randomized control studies were included in the review. These studies included all major and minor abdominal surgeries in the elderly (>65 years old) with the primary objective of investigating prevalence, predictors, prevention, or treatment for delirium.

    Data Extraction: Extraction of articles by authors using predefined data fields to conduct a systematic search including study quality indicators.

    Conclusions: Risk factors in this group can be best categorized as pre, intra and postoperative. Preoperative risk factors include disturbance of sleep wake cycles. Intraoperative risk factors include length and type of surgery, blood loss during procedure, tachycardia, and volume of crystalloid infusion needed. Regional anesthesia showed a greater risk in abdominal surgery, a trend in opposition to orthopedic procedures. Postoperatively, new cases mainly occur between day 1 and 3 after surgery, also, critical care unit stay, age are related to longer duration of delirium. Prevention is best addressed by minimizing risk factors. Haldol decreases the incidence of delirium within the first week of operation. Treatments for general surgery patients have shown various degrees of success in decreasing frequency and duration of delirium. This is an area of research that needs further double-blind controlled studies to reach more concrete conclusions.

    Objectives:

    1. To describe risk factors in an under-studied older general surgery patient population.
    2. To identify the prophylactic and treatment interventions available in this group of patients.
    3. To analyze the effectiveness of prophylactic and treatment interventions for older people undergoing major and minor abdominal surgery.

    Relevance:
    This review is relevant for consultation-liaison psychiatrists, general surgeons, critical care teams, and nurses dealing frequently with postoperative delirious patients.

     
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Section D:  Neuropsychiatry

  1. Biological Basis of Conversion Disorder: Lack of Distractibility
    Presenting Author:  Kemal Arikan
    Co-Author:  Burc Cagri Poyraz

    Little is known about the neurobiological basis of conversion disorder. Recent functional brain imaging and electro-physiological studies suggest that in conversion disorder, complex brain mechanisms linking volition, movement, and perception might be disrupted. A clinical feature of conversion disorder is that symptoms tend to diminish during the occasional distractions of the subject; hence, for instance, a pseudo-neurological symptom such as head or limb tremor might diminish in magnitude or totally disappear as the subject is distracted by intervening stimulus during examination. Following this clinical observation, we hypothesized that subjects exhibiting conversion symptoms could have alterations of attentive cognitive functions. In order to test this hypothesis, we investigated event related potential (ERP) responses to a novel oddball paradigm in a patient with prolonged conversion disorder. Novelty oddball paradigm has been selected in this study as its design tends to yield attentional cognitive functions. Subjects showed less then expected number of correct responses. They also produced abnormal N2, P3a and P3b waves latency and amplitude. We have investigated three subjects mimicking movement disorders. Since, a common interpretation of the P300 is that it reflects broad recognition and memory-updating processes while the P3a reflects a passive comparator and is a reflection of distractibility for unexpected stimuli. Therefore, our above findings suggest that during clinically active conversion symptoms, the subjects tended to be resistant to get distracted by unexpected and irrelevant stimuli.

    In summary, the study strongly suggests that the conversive patients have a difficulty in distracting their attentions.

    Objectives:

    1. Investigate electrophysiological background of conversion disorders.
    2. Test psychoactive agents influencing attention in patients with conversion disorders.
    3. Perhaps investigate further cognitive aspects in conversion disorders.

    Relevance:
    Conversion disorders are frequent in psychiatric practice, and little is known about their biological substrate.

     
  2. Caplan’s Sign: A Retrospective Study of Polyallergy as a Marker of Non-Epileptic Events in the Epilepsy Monitoring Unit
    Presenting Author:  Jason Caplan
    Co-Authors:  James Park, John Bokma, Kristina Chapple

    Background: Distinguishing epileptic from non-epileptic events can be difficult given similar motoric manifestations, especially if video EEG monitoring is not readily available. Previous reports have described markers such as the teddy bear sign, pelvic thrusting, eye closure, and itcal stuttering as indicative of non-epileptic events. We propose the polyallergy sign (i.e., a patient reporting four or more listed allergies – colloquially referred to at the Barrow Neurological Institute as "Caplan's sign") as the first chart-based sign to positively associate with non-epileptic diagnoses.

    Methods: A retrospective study of 1834 patients was conducted based on patient data gathered from the Barrow Neurological Institute Epilepsy Monitoring Unit between 2006-2012. A PERL script parsed through text document files to produce an Excel spreadsheet for statistical analysis. Univariate ANOVA was used to compare continuous outcome variables. Chi-square was used to cross tabulate categorical predictors by EEG outcome group. Logistic regression was used to predict non-epileptic EEG. ROC analysis determined the area under the curve and provided a criterion table with sensitivities, specificities, and predictive values for each value for number of allergies. MedCalc version 11.4 was used for ROC analysis. SPSS version 20 was used for all other analyses. ANOVA was used to examine mean differences for outcome variables number of allergies, proportion of patients with allergy, age, and gender by EEG outcome group. All ANOVAs are significant at p<0.001.

    Results: For every increase in number of allergies, odds of a non-epileptic diagnosis increase by 1.38 times.

    Conclusions: This study indicates that polyallergy is predictive of seizure-like events representing non-epileptic rather than epileptic pathology. To our knowledge, this would be the first reported sign associated with non-epileptic events that could be obtained from medical records without having the patient admitted to the hospital or a clinical description of the seizure-like event. This may allow for screening of large medical populations for risk of non-epileptic events or other psychosomatic illnesses. The etiology of the association between polyallergy and non-epileptic events is likely comprised of both biological (e.g., exposure to greater number of medications due to symptoms not improving with usual treatment) and psychodynamic factors (e.g., psychosomatic rejection of an agent intended to "treat" an immature defense).

    Objectives:

    1. Compare the existing clinical signs that have been positively associated with non-epileptic events.
    2. Analyze the data presented regarding polyallergy as a predictor of non-epileptic events.
    3. Explore how this predictive sign might be applied in large population groups such as epilepsy clinics or Accountable Care organizations.

    Relevance:
    Non-epileptic events are a costly and potentially dangerous manifestation of conversion disorder. This is the first reported chart-based sign predictive of these events and may allow for population-based screening.

     
  3. [T] Blink: The Power of a Paraneoplastic Syndrome
    Presenting Author:  Richard Carlson
    Co-Author:  Amanda Wilson

    Background: Adult-onset opsoclonus myoclonus syndrome (OMS) is a rare trigger for psychiatric consultation. Primarily seen as a pediatric paraneoplastic syndrome, OMS is distinguished by its ocular findings. Opsoclonus, the ocular manifestation of myoclonus, and myoclonus of the extremities characterize this syndrome. We report a case of a woman with a known neoplasm who presented along with family to the ED for evaluation of "a nervous breakdown" but was subsequently admitted medically after she was found to have delirium, opsoclonus, myoclonus, and ataxia.

    Case Report: A 67 year-old Caucasian woman with history of severe depression, recently diagnosed recurrent metastatic breast cancer, and prior history of ovarian and thyroid cancers presented from the Oncology Clinic for psychiatric evaluation of behavioral changes. Per her family, she experienced progressively worsening anxiety, depression, weakness, fatigue, anorexia, tremors, diarrhea, nausea and vomiting beginning shortly after learning of her recurrent breast cancer diagnosis one month ago. These symptoms were considered psychosomatic by her outpatient treaters. Her symptoms acutely worsened over three days with confusion, bizarre behavior, worsening tremor, inappropriate laughing, and stuttering speech.

    On exam, forced eye closure by the patient obscured the presence of opsoclonus and reinforced the impression that some of the symptoms were behavioral. Initial recommendations by neurology included head imaging and a psychiatric evaluation. Further evaluation by psychiatry revealed unusual eye findings concerning for opsoclonus, perseveration, impaired memory, affective lability, rigidity, facial myoclonus, and course tremor. Recommendations for medical admission to rule out a neurologic syndrome were made with specific concern for opsoclonus myoclonus syndrome. An EEG was notable for slow posterior dominant rhythm. CSF studies, a serum paraneoplastic panel, and laboratory studies were unrevealing. MRI demonstrated cerebellar metastases. Plasmapheresis and IV steroids were subsequently initiated for presumed OMS without significant improvement. Additional treatment, including ECT and treatment of the primary tumor, were both considered. After a goals-of-care discussion with the palliative consult team, the family ultimately decided on comfort care. The patient was discharged home with hospice on hospital day 16.

    Conclusion: This case report describes the presentation of a paraneoplastic syndrome rarely seen in adults known as opsoclonus myoclonus syndrome. OMS should be considered in adults who present with opsoclonus, the ocular manifestation of myoclonus. Although this patient’s symptoms did not improve with treatment, complete remission has been achieved with immunotherapy in other cases. Clinicians across all disciplines should be aware of this rare syndrome. For the general hospital psychiatrist, this case demonstrates the importance of the physical examination as well as the consideration of a broad differential of medical and neurological etiologies with the presentation of behavioral changes.

    Objectives:

    1. Define opsoclonus and the opsoclonus myoclonus syndrome.
    2. Note the importance of physical examination of the psychiatric patient in ruling out medical etiology of psychiatric symptoms.
    3. Note the importance of consideration of other medical etiologies of behavioral symptoms in the context of active medical disease, in particular malignancies that may present with paraneoplastic syndromes.

    Relevance:
    This case report describes the presentation of a paraneoplastic syndrome rarely seen in adults, known as opsoclonus myoclonus syndrome, that was initially thought to be behavioral by family and treaters.

     
  4. [T] Assessing Psychosis in Deaf Patients
    Presenting Author:  Priyanka Deshmukh
    Co-Author:  Raman Marwaha

    Purpose: To highlight the challenges encountered by clinicians in accurately assessing symptoms of thought disorganization in deaf psychiatric patients.

    Methods: Case Report: We present the case of a 34 yr old male patient with history of schizophrenia, paranoid type. He was a deaf-mute patient who presented with auditory and visual hallucinations of ghosts, spirits, and dead people. During this patient's admission the team faced challenges in accurately assessing symptoms of thought disorganization. A device called Deaf Mute Talk was utilized to minimize the communication barrier and help assess psychotic symptoms.

    Result: The issue of language dysfluency in a substantial number of deaf psychiatric inpatients is a significant factor that poses a barrier in accurate assessment of psychosis in this population.

    Conclusion: It is crucial for clinicians to be aware of possible limitations, such as language and cultural differences, while diagnosing and treating deaf people with psychotic disorders to provide quality patient care.

    References:

    1. Black P, Glickman NS: Demographics, psychiatric diagnosis, and other characteristics of North American deaf and hard-of-hearing inpatients. J Deaf Stud Deaf Educ 2006; 11(3):303-21.

    2. Atkinson JR, Gleeson K, Cromwell J, O'Rourke S: Exploring the perpetual characteristics of voice-hallucinations in deaf people. Cogn Neuropsychiatry 2007; 12(4):339-61.

    3. Glickman N: Do you hear voices? Problems in assessment of mental status in deaf persons with severe language deprivation. J Deaf Stud Deaf Educ 2007; 12(2):127-47.

    4. Thacker A: Formal communication disorder: sign language in deaf people with schizophrenia. Br J Psychiatry 1994; 165:818-23.

    5. Schick B, De Villiers P, De Villiers J, Hoffmeister R: Language and "theory of mind": a study of deaf children. Child Dev 2007; 78:376-96.

    Objectives:

    1. Awareness in accurately identifying and assessing psychosis in deaf psychiatric patients compared to diagnosing psychosis in the hearing population.
    2. Challenges the clinician is likely to face in lieu of confounding factors in deaf psychiatric patients.
    3. Highlight the differences between symptoms of psychosis vs. symptoms due to language dysfluency.

    Relevance:
    Hope that increased attention and systematic studies for this under-served population will be more widely recognized as unique and more accuretely assessed by the mental health community as a whole.

     
  5. WITHDRAWN
     
  6. [T] Unintentional Injuries in Patients with Dementia: Hospital Course and Outcomes
    Presenting Author:  Elizabeth B. Gilbert
    Co-Authors:  Daithi S. Heffernan, Colin J. Harrington

    Objective: Trauma remains a large cause of morbidity and mortality in the United States, and patients with chronic medical conditions have poorer outcomes. Little is known about the specific impacts that neuropsychiatric conditions have on the hospital course and outcomes of unintentionally injured trauma patients. Our hypothesis is that patients with pre-existing neuropsychiatric disorders such as dementia, may have elevated baseline inflammatory profiles, potentially increasing the risk for a dysregulated stress response, leading to poor outcomes and delayed recovery. We aimed to examine the prevalence of dementia in the adult trauma population, and investigate whether patients on dementia medications had different hospital courses or outcomes.

    Methods: This is a retrospective chart review of unintentionally injured trauma registry patients between 18 and 99 years old that presented to a level 1 trauma center over a 5-year period. Information on patient demographics, injuries, hospital course and mortality were obtained from the trauma registry. Admission medications and chronic psychiatric and medical problems were obtained from the patient chart. Dementia medications included cholinesterase inhibitors (ChEI) and memantine.

    Results: 448 patients carried a dementia diagnosis. 199 (44%) of the dementia patients were on a ChEI and/or memantine on admission. 10 (5%) patients on dementia medications died, while 27 (10.8%) of the patients without dementia medication died (p=0.026). There was no significant difference in gender, age, presence of comorbid psychiatric conditions, or average number of additional psychotropic medications between the two groups. In addition, there was no significant difference in mechanism of injury, injury severity, infection rate, ICU admissions, or length of hospitalization. After controlling for confounding factors, not being on dementia medications was found to be independently associated with mortality. Injury severity score and age were also each independently associated with mortality.

    Conclusions: Treatment of dementia with ChEI inhibitors or memantine may be a positive prognostic indicator in acutely injured trauma patients with dementia. It is unclear whether this finding relates to the pharmacological actions of the medications themselves, or whether it is a marker of other factors such as general health status, access to care, provider adherence with treatment guidelines, or patient compliance with care.

    Objectives:

    1. Recognize that dementia is a common neuropsychiatric disorder in trauma patients.
    2. Understand the impact that chronic medical conditions can have on trauma outcomes.
    3. Explore the potential positive effect of dementia medications on trauma recovery.

    Relevance:
    This study discusses the prevalence and significance of dementia in unintentionally injured trauma patients.

     
  7. [T] Dementia with Lewy Body Presenting with Delusion of Parasitosis
    Presenting Author:  Mencia Gómez De Vargas
    Co-Authors: Ali Khadivi, Yonas E. Geda

    Introduction: Dementia with Lewy body (DLB) is associated with hallucinations and delusions. Little is known if DLB presents with delusion of parasitosis.

    Case Report: Here we report the case study of a 69 year old, left-handed, male patient who is originally from the Dominican Republic. He has no known past psychiatric history. His medical history is significant for hypertension, type II diabetes mellitus, hepatitis C, and arthritis.

    The patient presented with an alarming sensation of "insects entering his eyes, nose and mouth." His primary care physician referred him to Ophthalmology for further evaluation, but after extensive evaluation there was no evidence of insects or other foreign bodies. The ophthalmologist then referred the patient to the Department of Psychiatry. The patient felt disturbed by the symptom, made goggles out of a mosquito net and began wearing them. The goggles appeared quite disgusting to family members and others but the patient felt that initially they helped him in decreasing the "biting" sensation. After a few weeks the goggles were of no help; rather, he felt ashamed and isolated at his home.

    During the psychiatric evaluation, the patient and family members both reported a one-year history of forgetfulness and difficulty with sense of direction. There was no associated auditory hallucination.

    The patient was given risperidone 0.5 mg at bedtime. However, after several weeks he developed marked Parkinsonism and therefore was switched to quetiapine 12.5mg at bedtime. Again the patient developed marked rigidity and bradykinesia.

    Laboratory tests showed normal porphyrins, iron studies, slightly increased ALT, negative RPR, normal urinalysis and negative urine toxicology. The brain MRI showed mild cerebral atrophy with prominent third, lateral ventricles and cortical sulci. He did not complete neuropsychological testing; however, during the 8-month follow up he showed decreased executive functioning as measured by Montreal Cognitive Assessment Test and fluctuations in the Mini-Mental State Exam. The family members also reported that the patient was rambling loud and displaying flailing movements while sleeping. His clinical evaluation showed autonomic instability as well. The differential diagnosis included dementia, extra-hepatic complications of hepatitis C, and diabetic neuropathy.

    Discussion: The unique feature of this case is that the patient presented with delusion of parasitosis after an insidious onset of problems with memory, attention, and sense of direction.

    Additionally, he displayed fluctuations in his attention, became increasingly drowsy at daytime, had dream enactment behavior and marked sensitivity to neuroleptics. The patient meets the McKeith Criteria for probable DLB, however, this does not rule out the possibility of other dementias.

    Conclusion: In an elderly person that presents with delusion of parasitosis and cognitive impairment, one may consider DLB in the differential diagnosis.

    Objectives:

    1. Understand the spectrum of manifestations of Lewy Body Disease.
    2. Review the diagnosis of delusion of parasitosis in the elderly population.
    3. Review the McKeith Criteria for the diagnosis of Lewy body dementia.

    Relevance:
    Delusion of parasitosis is an unusual presentation of Lewy body disease and this is one of the first case reports described in the literature.

     
  8. [T] Psychiatric Manifestations of CLIPPERS (Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids)
    Presenting Author:  Daniel Hosker
    Co-Authors: Ian Steele, Dylan Kathol, Nathaniel Barusch, Lance Rouse, Jason Caplan

    Introduction: Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a relatively newly described disorder whose cardinal radiologic feature is punctate gadolinium enhancement "peppering" the pons on MRI. Spread into the cerebellum, spinal cord, and basal ganglia can be seen, along with cerebral atrophy. Little has been reported on the neuropsychiatric manifestations of this disease. Due to the characteristic locations of lesions and the potential for disruption of neural circuitry, including those involved in emotional control and behavior, it is possible that CLIPPERS may present with neuropsychiatric symptoms. Here, we report the case of a patient recently diagnosed with CLIPPERS who presented with emotional lability.

    Case: Ms. A was a 40 year-old woman with diabetes mellitus type 2, CLIPPERS diagnosed one year prior, and no prior psychiatric history who was admitted with intractable nausea and vomiting. Psychiatry was consulted due to bizarre and aggressive behavior. Per nursing report, the patient was emotionally labile, demanding, paranoid that medical staff were persecuting her, and had been sneaking sugary soda and donuts into her room despite her diabetic diet. Ms. A vehemently refused to engage in psychiatric evaluation, becoming angered at the suggestion. No evidence of imminent dangerousness was found to allow for involuntary psychiatric evaluation or treatment.

    MRI of the brain revealed patchy areas of T2 and FLAIR enhancement of the pons and cerebral peduncles consistent with CLIPPERS. The distribution of lesions had changed since her last MRI, now showing greater advancement on the right side.

    Review of the medical record revealed multiple admissions over the course of the year since her CLIPPERS diagnosis. She had been on chronic steroid treatment throughout, but only in the past couple of months had begun exhibiting the labile and paranoid behavior that had prompted psychiatric consultation. While it was possible that steroid treatment had contributed to her symptoms, the location and advancement of her lesions are also likely to have played a role.

    Results: Disruption of the limbic system can manifest with emotional, behavioral, and motivational symptoms. For example, neuro-Behcet's disease, which demonstrates a pattern of pontine and cerebellar peduncle lesions similar to that of CLIPPERS, can manifest psychiatric symptoms including psychosis, affective symptoms, and personality changes.

    Lesions in CLIPPERS are characteristically distributed in the cortico-ponto-cerebellar pathway implicated in pseudobulbar affect. Interestingly, pseudobulbar affect was noted in 3 of the 5 patients in one of the first papers describing patients with CLIPPERS without further discussion.

    Conclusions: Due to the localization of lesions present in CLIPPERS that may predispose to neuropsychiatric symptoms, psychiatrists should be familiar with its pathophysiology and recommended treatment.

    Objectives:

    1. Define the pathophysiology and characteristic lesions of CLIPPERS.
    2. Apply basic concepts of the neuroanatomy and function of the limbic circuit to the clinical findings of CLIPPERS.
    3. Analyze the options for treatment of neuropsychiatric symptoms that may be caused by CLIPPERS.

    Relevance:
    CLIPPERS is a relatively newly described neurologic diagnosis. The characteristic distribution of lesions in CLIPPERS is likely to produce a variety of psychiatric symptoms, about which little has been reported.

     
  9. [T] Temporal Seizure Focus Presenting with Psychosis: A Case Report and Literature Review
    Presenting Author:  Walter Kilpatrick
    Co-Authors:  Cameron Bonney, Daniel Price

    Purpose: Since the 19th century, psychiatrists and neurologists have described an association between psychosis and epilepsy. A distinct nomenclature has been produced relating the symptoms of psychosis temporally to the seizure activity that includes ictal psychosis, interictal psychosis, and postictal psychosis. [1, 2, 3, 4]

    The purpose of this paper is to describe a case of temporal seizure focus presenting with symptoms of psychosis and review the literature examining the association between psychosis and epilepsy. We offer a case report which describes the clinical, electroencephalographic, and neuroimaging findings in a 68 year old male with history of vascular dementia who experienced an acute onset of agitation and paranoia associated with a temporal seizure focus that responded to treatment with valproic acid.

    Methods: We collaborated with the Maine Medical Center Department of Neurology and Electroencephalographic Laboratory. The EEG study was obtained utilizing the 10-20 international system of electrode placement. We utilized PubMed and Medline for our literature review.

    Results: Our patient presented with psychiatric symptoms including paranoia and aggression with violence, thought to be psychotic in nature. They occurred in conjunction with brief stereotypic events of yelling, agitation, and restlessness. EEG was obtained after the patient was witnessed to have rhythmic like movements involving upper extremities and identified a temporal seizure focus. Treatment with valproic acid resulted in seizure control and resolution of psychotic symptoms.

    Conclusions: The clinical presentation of specific psychotic symptoms including agitation, fear and paranoia along with the concordant temporal relationship of the partial complex temporal lobe seizures to the psychotic symptoms led us to the conclusion that the patient was experiencing an ictal psychosis.

    Ictal psychosis is one of three types of psychotic syndromes associated with epilepsy along with interictal psychosis which is further subdivided into brief and chronic interictal psychosis and finally postictal psychosis. [1, 2, 3, 4] Unidentified cortical seizures can lead to complex behaviors that present as functional psychotic symptoms. It is useful to identify the three archetypal psychotic syndromes associated with epilepsy to assure proper treatment.

    References:

    1. Farooq S, Sherin A: Interventions for psychotic symptoms concomitant with epilepsy. Cochrane Database of Systemic Reviews 2008; Issue 4, Art. No.: CD006118.

    2. Nadkarni S, Arnedo V, Devinsky O: Psychosis in epilepsy patients. Epilepsia 2007; 48(Suppl. 9):17-19.

    3. Lancman M: Psychosis and peri-ictal confusional states. Neurology 1999; 53(5):S33-S38.

    4. Leutmezer F, Podreka I, Asenbaum S, Pietrzyk U, Lucht H, Back C, Benda N, Baumgartner C: Postictal psychosis in temporal lobe epilepsy. Epilepsia 2003; 44(4):582-590.

    5. Jobst B, Williamson P: Frontal lobe seizures. Psychiatr Clin N Am 2005; 28:635-651.

    Objectives:

    1. Describe a case of temporal seizure focus presenting with symptoms of psychosis.
    2. Describe the three archetypal psychotic syndromes associated with epilepsy in the current literature.
    3. Investigate the association between psychotic symptoms and seizure activity as relevant to the case.

    Relevance:
    As consultation-liaison psychiatrists asked to see patients presenting with psychotic symptoms in the hospital setting, it is pertinent to identify psychotic syndromes associated with epilepsy to assure proper diagnosis and treatment.

     
  10. [T] Case report: Mania with Psychotic Features - Status Post Right Temporal Lobectomy
    Presenting Author:  Ah Young (Nora) Kim
    Co-Authors:  Maria Theresa Mariano, Biswarup Ghosh

    Introduction: Mania due to temporal lobe surgeries is rare and reports have been scant and limited to patients with refractory epilepsy [1]. This report presents a case of a patient who developed acute mania with psychotic symptoms after temporal lobectomy.

    Case: A 34 year old female with a recent temporal tumor resection presented to her postoperative neurosurgery follow-up tangential and delusional. She was admitted to the hospital for management of delirium. She was on a dexamethasone taper postoperatively, which was discontinued. Levetiracetam was continued and carbamazepine was added. Quetiapine was started for her psychosis and dangerous behavior. Once her delirium resolved, she was transferred to psychiatry. She was hyper-verbal, tangential, labile, somatic and grandiose. Her family members stated they had noticed an abrupt change in her behavior right after the surgery: decreased sleep, over-productive speech, impulsivity, and aggressiveness. While in the psychiatric unit, levetiracetam was tapered off and she was continued on quetiapine. Carbamazepine was gradually increased. Her manic and psychotic symptoms gradually resolved.

    Discussion: The complexity of this case may be due to several factors. She initially presented with delirium. However, once delirium resolved she continued to exhibit manic and somatic symptoms which could be attributed to the location of the resection. A study found that 3.9% of temporal lobectomies developed new onset mania [3]. The literature also suggested an association between psychoses and right-sided lobectomy [4]. Consistent with our case, several studies reported an association of congenital lesions, such as dysembryoblastic neuroepithelial tumors with psychosis following temporal lobectomy [5]. It is worthwhile to note that there are other factors that might have contributed to this patient's symptoms. She was on dexamethasone and levetiracetam, both of which can precipitate psychosis and mania. However, the symptoms remained for weeks after discontinuation of dexamethasone. She was also on levitiracetam for years prior to the surgery without development of psychotic or manic symptoms. Thus, these medications appear to be exacerbating factors rather than primary etiologies of her symptoms. Her symptoms were effectively treated with carbamazepine and quetiapine.

    References:

    1. Mayanagi Y, et al: Psychiatric and neuropsychological problems in epilepsy surgery: analysis of 100 cases that underwent surgery. Epilepsia 2001; 42 Suppl 6.

    2. Kanemoto K: Hypomania after temporal lobectomy: a sequela to the increased excitability of the residual temporal lobe? J Neurol Neurosurg Psychiatry 1995; 59(4).

    3. Carran MA, Kohler CG, et al: Mania following temporal lobectomy. Neurology 2003; 61(6).

    4. Trimble MR: Behaviour changes following temporal lobectomy, with special reference to psychosis. J Neurol Neurosurg Psychiatry 1992; 55(2).

    5. Shaw P, et al: Schizophrenia-like psychosis arising de novo following a temporal lobectomy: timing and risk factors. J Neurol Neurosurg Psychiatry 2004; 75(7).

    Objectives:

    1. Discuss potential idiopathic etiologies that could be implicated in the causation of or exacerbation of psychiatric symptoms in a patient in a patient after a tumor resection.
    2. Create awareness about the potential psychiatric symptomatology that might present after a right temporal lobectomy.
    3. Identify potential treatment approaches to new onset mania and psychosis after a right temporal lobectomy.

    Relevance:
    Right temporal lobectomy has been associated to new onset mania and psychosis. This case of mania with psychotic features identifies a comprehensive psychopharmacological approach towards treatment of such a case.

     
  11. [T] First-Episode Psychosis Diagnosed with Neuropsychiatric Systemic Lupus Erythematosus (NPSLE) during Psychiatric Hospitalization: Case Report and Literature Review
    Presenting Author:  Subani Maheshwari
    Co-Authors:  Adele Veksman, Christopher Burke

    Background: The American College of Rheumatology has defined 19 neuropsychiatric syndromes associated with systemic lupus erythematosus. In about 60% of the cases neuropsychiatric disease can be attributed to SLE itself and is referred to as primary NPSLE. In the remaining 40%, neuropsychiatric symptoms are secondary to infections, drug side effects, and/or metabolic derangement.

    Case: An 18 year old African American female presented with first episode of acute onset psychosis. Her past history included anemia, some vague joint pain, and a remote history of depression treated by psychotherapy. Treatment was started with risperidone. During the course of hospitalization, she developed thrombocytopenia, drooling, mutism, psychomotor retardation and autonomic instability requiring transfer to the medical floor. Risperidone was discontinued and an extensive work up was performed to rule out neuroleptic malignant syndrome, autoimmune and neurological disorders. Her presentation progressed to catatonia. She received benzodiazepines and showed significant improvement. The lab results pointed towards SLE and high dose oral prednisone was started. Lupus cerebritis was confirmed with positive Ribosomal P protein antibody. Quetiapine and valproic acid were started for psychosis and mood lability respectively. The patient’s condition gradually improved. She was discharged after a hospital course of five weeks. She followed up at the psychiatry outpatient clinic. Benzodiazepine and the psychotropics were gradually tapered off.

    Discussion: The integrity of the blood–brain barrier seems to play an important role in autoantibody mediated CNS manifestations by causing neuronal death. Common manifestations of NPSLE are cognitive dysfunction (27%), headache (23%), mood disorders (8%), and psychosis (6%). Catatonia has been reported in a few patients with SLE. MRI is the diagnostic test of choice but in approximately 70% of cases MRI shows no or non specific abnormalities. We have described a patient who presented with psychosis and catatonia with no known history of SLE. She was extremely sensitive to antipsychotic medications initially but responded well to benzodiazepines and steroids.

    References:

    1. Meszaros ZS, Perl A, Faraone SV: Psychiatric symptoms in systemic lupus erythematosus: A systemic review. J Clin Psychiatry 2012; 73(7):993-1001.

    2. Adekola A, Chlebowski S, Chung C: Neuropsychiatric systemic lupus erythematosus presenting as bipolar I disorder with catatonic features. Psychosomatics 2009; 50(5):543-7.

    3. Bruns A, Meyer O: Neuropsychiatric manifestations of systemic lupus erythematosus. Joint Bone Spine 2006; 73(6):639-45.

    4. Wang HY, Huang TL: Benzodiazepines in catatonia associated with systemic lupus erythematosus. Psychiatry Clin Neurosci 2006; 60(6):768-70.

    Objectives:

    1. To formulate differential diagnosis for first-episode psychosis.
    2. Recognize neuropsychiatric symptoms of systemic lupus erythematosus.
    3. Increase knowledge about diagnostic tests and treatment of NPLSE.

    Relevance:
    Neuropsychiatric symptoms could be the initial manifestation of systemic lupus erythematosus. It is the second major cause of morbidity and mortality in SLE and requires prompt diagnosis and treatment.

     
  12. [T] A Case of Factitious Disorder Presenting as Advanced Parkinson's Disease
    Presenting Author:  Aileen Park
    Co-Author:  Maria Fernanda Gomez

    Purpose: Factitious presentations of Parkinson's disease (PD) are uncommon, with no identified case reports in the literature. When suspecting factitious PD, the concept of levodopa addiction should also be considered in the differential diagnosis. The authors review an unusual case of factitious disorder with Parkinsonism in a patient with apparent Munchausen's syndrome in order to highlight the complexity of such cases and the risks of iatrogenic complications.

    Methods: We present the case of a 55 year-old woman with history of early onset PD sent from her nursing home for worsening symptoms. Her initial diagnosis of PD was made over fifteen years prior, and she had been residing in nursing homes for at least ten years, receiving high doses of carbidopa/levodopa with inadequate symptom control. After thorough evaluation by the medicine and neurology services, including on-off studies conducted by movement disorders specialists, her dose of carbidopa/levodopa was titrated to 25mg/100mg every 90 minutes and she was deemed appropriate for deep brain stimulation (DBS) at an outside hospital. During the required drug washout period prior to DBS, she was captured on video moving fluidly, including fine motor movements, when alone in her room. As a result, she was considered ineligible for DBS and readmitted to our hospital for a controlled taper of carbidopa/levodopa.

    Results: Without video evidence, the diagnosis of PD was never questioned; daily neurologic exams and nursing home records were consistent with her ostensibly longstanding illness. Retrospective examination of the records revealed subtle aspects of her history that pointed to a diagnosis of factitious disorder, including vague details about her initial diagnosis and her lack of social support—she received no visitors during a month-long admission and had a court-appointed legal guardian. She was often highly demanding of staff, requesting higher doses of levodopa despite evidence of toxicity. Aspects of Munchausen's syndrome were present, in that she had recurrent hospitalizations and peregrination between at least ten nursing homes in the region.

    Conclusions: Recognizing factitious disorders in hospitalized patients is necessary for accurate diagnosis and treatment. Though factitious PD is not common, atypical presentations and levodopa addiction should raise some suspicion. When the diagnosis of PD is uncertain, some clinicians recommend first confirming nigrostriatal dopaminergic dysfunction using fluorodopa-PET imaging prior to considering DBS. This case is a reminder that proper diagnosis is essential in order to avoid unnecessary tests and invasive procedures.

    References:

    1. Abermoon P, et al: Compulsive use of dopamine replacement therapy: a model for stimulant drug addiction? Addiction 2011; 107:241-247.

    2. Pourfar, et al: Using imaging to identify psychogenic parkinsonism before DBS. J Neurosurg 2012; 116:114-118.

    3. Zaharna M, et al: Levodopa addiction and factitious disorder in a patient with idiopathic Parkinson’s disease. J Neuropsychiatry Clin Neurosci 2010; 22:3:E11-12.

    Objectives:

    1. Review factors that can raise the possibility of factitious disorder, including lack of collateral information, peregrination, inconsistencies in medical history, and atypical presentations.
    2. Consider the possibility of levodopa addiction in a patient requiring higher doses of dopamine replacement therapy.
    3. Use fluorodopa-PET imaging techniques if the diagnosis of PD is uncertain prior to considering more invasive procedures such as deep brain stimulation.

    Relevance:
    Factitious disorders rarely present as advanced Parkinson’s. Atypical presentations should clue the clinician to consider factitious disorder. High doses of dopamine replacement therapy should lead to consideration of levodopa addiction.

     
  13. Inflammation and Psychosomatic Medicine
    Presenting Author:  Lisa J. Rosenthal
    Co-Authors:  Robert Weinrieb, Robert Brett Lloyd, Christian G. Kohler, Nicholas Tsopelas

    Inflammation is increasingly implicated in the predisposition, pathophysiology, and perpetuation of many disease states, and the goal of this poster is to provide a framework for understanding inflammatory mechanisms in medical and psychiatric disease. There is also growing evidence of the relationship between psychiatric symptoms and higher rates of medical morbidity and mortality, which may be mediated in part by inflammatory processes and stress responses. We look at a variety of common diagnoses and review the possible impact of inflammatory pathways, their impact on psychiatric symptoms, and discuss the implications for integrated treatment.

    The psychiatric diagnoses reviewed include schizophrenia, immunosuppressant associated psychosis, acute stress disorder, delirium, and traumatic brain injury. Each presentation will review the evidence base supporting the role of inflammatory processes in the pathophysiology and comorbidities of these psychiatric syndromes. Understanding inflammatory pathways, cytokines and other markers, their impact on psychiatric symptoms, and their medical sequelae may be increasingly important for the integrated psychosomatic psychiatrist.

    All authors are experienced members of the psychosomatic consultation service at Northwestern Memorial Hospital and the Hospital of the University of Pennsylvania, which provide comprehensive inpatient and outpatient services to large and diverse patient populations.

    Objectives:

    1. Provide a framework for understanding inflammatory mechanisms in medical and psychiatric disease.
    2. Understand inflammatory pathways in the relationship between psychiatric symptoms and higher rates of medical morbidity and mortality.
    3. Understand how acute stress can affect inflammation and medical and psychiatric symptoms.

    Relevance:
    Understanding inflammatory pathways, cytokines and other markers, their impact on psychiatric symptoms, and their medical sequelae may be increasingly important for the integrated psychosomatic psychiatrist.

     
  14. [T] Escitalopram Monotherapy Reduces the Syntheses of Neurotoxic Metabolites in the Serum of Patients with Major Depression
    Presenting Author:  Vidushi Savant
    Co-Authors:  Angelos Halaris, Aye-Mu Myint, Edwin Meresh, Guilles Guillemin, James Sinacore

    Purpose: Escitalopram (ESC) is a selective serotonin reuptake inhibitor (SSRI) which exerts its action by binding to the serotonin transporter thereby enhancing the activity of released serotonin at postsynaptic serotonin receptors. This is presumed to be the mechanism by which these agents exert their antidepressant effect. A pro-inflammatory state has been convincingly demonstrated in depression. Similarly, an imbalance in the tryptophan/kynurenine pathway has been reported in depression with altered levels of metabolic products. An association has been postulated between the pro-inflammatory status and the shunt of tryptophan to the kynurenine pathway and away from serotonin synthesis in depression. This study sought to replicate these findings and determine whether escitalopram treatment could reverse the changes in kynurenine metabolites in patients with major depressive disorder (MDD).

    Method: This was an open label trial that included 30 patients diagnosed with MDD by means of structured interview (MINI). After completing baseline (BL) assessments, patients were started on a 12-week monotherapy course with ESC following a 2-4-week drug washout, as appropriate. Clinical assessments were carried out at each visit using the HAM-D, HAM-A, CGI and BDI rating scales. Early morning fasting venous blood samples were collected at each assessment and serum samples were separated and stored at -80°C till analyzed. Cytokines were analyzed with Randox multiplex assay and tryptophan and kynurenines were analyzed using HPLC/GC as described previously. Blood levels of ESC were also determined.

    Results: Evidence for a pro-inflammatory status was obtained. BL Interleukin (IL)-6 level was significantly higher (p=0.036) in the patients compared to healthy control subjects as was hs CRP. TNFalpha trended toward an increase. BL IL-1b level showed a significant positive association with IL-1α, IL-4 and 3-hydroxykynurenine (3HK). Spearman correlation revealed:

    • The lower the BL Kynurenic Acid (KYNA), the higher the depressed mood (-0.492, p=0.011).
    • BL IL-4 level was negatively correlated with the guilt sub score on HAM-D (-0.416, p=0.039).
    • Higher BL 3HK (0.48, p=0.013), Interferon gamma (IFNg) (0.48, p=0.015) and TNFα (0.403, p=0.046) were correlated with lower interest in work and activities.
    • High hsCRP was associated with high psychomotor retardation score on HAM-D (0.473, p=0.015).
    • The lower the KYNA, the higher the paranoid ideation score on HAM-D (-0.438, p=0.025).

    During the course of treatment, serum concentrations of CRP (p=0.042), 3HK (p<0.0001), Quinolinic Acid (QUIN) (p<0.001), QUIN/Kynurenine (KYN) (p=0.052), 3HK/KYN (p<0.0001), KYN/tryptophan (TRYP) ratio (p=0.004), IL-6 (p=0.016) and IL-10 (p=0.047) significantly decreased and TRYP (p=0.014) significantly increased. The mean baseline hsCRP was lower (p=0.002) in the responders when compared with non-responders.

    Conclusion: The results of our study indicate that apart from the selective inhibition of serotonin reuptake, the antidepressant effect of ESC might occur through reduction of neurotoxic kynurenine metabolite synthesis and/or release.

    Objectives:

    1. Learn to associate knowledge on neuroinflammatory hypothesis of depression to presenting symptoms of depression.
    2. Learn which cytokines in body are associated with depression and how the levels of cytokines may change with treatment by anti-depressant escitalopram.
    3. Have greater understanding of possible mechanisms of action of selective serotonin re-uptake inhibitors such as escitalopram and a better insight in to the anti-inflammatory and neuroprotective action of such medications.

    Relevance:
    Role of pro-inflammatory state, cytokines, and neurotoxic metabolites in causing symptoms of depression. Response of neurotoxic metabolites to treatment with escitalopram. Insight into search for biomarkers for depression and treatment response.

     
  15. [T] Quetiapine Monotherapy Reduces Neurotoxic Metabolite of the Kynurenine Pathway in Patients with Major Depression
    Presenting Author:  Vidushi Savant
    Co-Authors:  Angelos Halaris, Aye-Mu Myint, Edwin Meresh, Gilles Guillemin, James Sinacore

    Purpose: A pro-inflammatory state has been convincingly demonstrated in depression. Similarly, an imbalance in the tryptophan/kynurenine pathway has been reported in depression with altered levels of metabolic products. An association has been postulated between the pro-inflammatory status and the shunt of tryptophan to the kynurenine pathway and away from serotonin synthesis in depression. Quetiapine (QTP) is an atypical antipsychotic, but in lower doses it has been shown to exert antidepressant and anti-anxiety activity when used adjunctively for the treatment of bipolarand unipolar depressed patients. This activity is possibly related to the biologically active metabolite, norquetiapine. This study sought to establish the antidepressant efficacy of QTP as monotherapy in major depression (MDD) while also investigating the potential of this agent to reverse the changes in kynurenine metabolites in MDD patients.

    Methods: A total of 47 patients were enrolled after a structured interview (MINI) to confirm the diagnosis of MDD. Subjects completed the baseline (BL) assessments after undergoing a 2-4 week drug washout, as appropriate. They were then started on a 12-week low dose QTP monotherapy regimen in an open label study. Clinical assessments were carried out at each visit (week 1, 2, 4, 8 and 12) using the HAM-D, HAM-A, CGI and BDI rating scales. Early morning fasting venous blood samples were collected at each assessment. Serum samples were separated and stored at -80°C until analyzed. Cytokines were analyzed with Randox multiplex assay and Tryptophan/Kynurenine metabolites were analyzed with HPLC/GC. Blood levels of QTP and norquetiapine were also measured.

    Results: Firstly, the study confirmed the antidepressant efficacy of QTP in reducing significantly depressed mood, anxiety and insomnia in MDD patients with a large percentage of patients achieving remission with excellent safety and tolerability. With respect to inflammation and the “kynurenine shunt” the results are as follows:

    At baseline, serum hsCRP (p<0.0001), Kynurenine (p=0.011), Interleukin (IL)-4 (p=0.047), IL-6 (p=0.012), IL-1α (p=0.003) levels was significantly higher in MDD patients as compared to healthy control subjects.

    The baseline Tumor Necrosis Factor (TNF)-α level showed a significant negative correlation with tryptophan (TRY) level and serum IL-1α showed a positive correlation with IL-6 and 3-hydroxykynurenine (3HK).

    The Spearman Correlation analyses revealed:

    • Higher BL 3HK was associated with higher scores for depressed mood on HAM-D (0.398, p=0.032)
    • Higher Quinolinic Acid (QUIN) was associated with higher psychomotor agitation (0.448, p=0.017)
    • Higher 3HK was associated with higher score for lack of sexual interest (0.450, p=0.014)

    During the course of treatment serum concentrations of 3HK (p=0.003) were reduced significantly.

    Conclusion: This study confirmed the antidepressant efficacy of QTP monotherapy. Additionally, reduction of the neurotoxic metabolite, 3HK, may be a neuroprotective effect of QTP contributing to its mechanism of action.

    Objectives:

    1. Learn possible mechanism of action of quetiapine, an antipsychotic in alleviating depression and anxiety.
    2. Learn effects of quetiapine with various cytokines and neurotoxic metabolites in depressed patients and its possible neuroprotective potential.
    3. Gain more knowledge on neuroinflammatory hypothesis of depression and interaction of various metabolites involved in this hypothesis with quetiepine.

    Relevance:
    Learn about clinical and biochemical effect of low dose quetiapine monotherapy on patients with depression. Gain knowledge on neuroinflammatory hypothesis of depression and use of newer medications like quetiapine for depression.

     
  16. [T] Late-Onset, Cholinesterase Inhibitor-Induced Bipolar Illness
    Presenting Author:  Samuel O. Sostre
    Co-Authors:  Mahreen Raza, Yasmeen Abdul-Karim, Ankur Patel

    Purpose: The emergence of affective symptoms in an elderly patient with no psychiatric history should prompt a search for secondary causes. Acetylcholinesterase inhibitors are approved for the treatment of Alzheimer's dementia. The cholinergic system has been long implicated in the pathogenesis of affective disorders. Several case reports documenting acetylcholinesterase inhibitor-induced mania have been published.

    Methods: We present a case of suspected donepezil-induced bipolar affective illness in a patient with Alzheimer's dementia without pre-existing psychiatric illness.

    Results: A 92 year-old Caucasian female with Alzheimer's dementia with no personal or family history of psychiatric disorder presented for evaluation with family members. On examination, she presented as hyperactive, had pressured speech, flight of ideas, grandiosity, paranoia, and she endorsed euphoric mood. Collateral information from daughter revealed that weeks prior to presentation, patient had depressive symptoms but behavior had recently changed as patient was no longer sleeping, demonstrated increased activity level and participation in goal-directed activities. Patient had also been increasingly irritable, aggressive and violent. For treatment of cognitive deficits, patient had been prescribed donepezil 10mg daily and memantine 10mg twice daily for many months. Behavioral symptoms had been unsuccessfully treated with quetiapine 25mg PO three times daily. There had been no significant changes in laboratory values or neuroimaging. On admission, donepezil was discontinued with all other medications unchanged. Behavior rapidly improved with resolution of affective symptoms. She was discharged 5 days later at baseline mental status as per family.

    Conclusions: Cholinesterase inhibitors, such as donepezil, are approved for mild to moderate dementia. In 1972 Janowsky proposed the "cholinergic-adrenergic hypothesis of mania and depression" which predicts depression with procholinergic agents and mania in cholinergic deficient states. However, multiple reports of donepezil and other cholinesterase inhibitors leading to mania are emerging. It is not known via what mechanism this occurs, however, it is known that the cholinergic system interacts with various other neurotransmitter systems. Thus, donepezil may lead to a secondary alteration in these networks producing mania. This current case report hopes to add to the literature and to make consultation psychiatrists aware of this possible adverse effect of this class of medications.

    References:

    1. Collins C, et al: Bipolar affective disorder, type II, apparently precipitated by donepezil. Int Psychogeriatr 2011; 23(3):503-4.

    2. Burt T, et al: Donepezil in treatment-resistant bipolar disorder. Biol Psychiatry 1999; 45(8):959-64.

    3. Burt T: Donepezil and related cholinesterase inhibitors as mood and behavioral controlling agents. Curr Psychiatry Rep 2000; 2(6):473-8.

    4. Ehrt U, Fritze F, Aarsland D: Mania after administration of cholinesterase inhibitors in patients with dementia and comorbid bipolar disorder: two case reports. J Clin Psychopharmacol 2011; 31(2):254-6.

    Objectives:

    1. Understand the cholinergic-adrenergic hypothesis of mania and depression.
    2. Be aware of rare toxicity of donepezil.
    3. Understand the need to search for secondary causes of psychiatric symptoms in patients with atypical presentation.

    Relevance:
    With a rapidly aging population, more patients will undoubtedly receive treatment with cholinesterase inhibitors. Consultation psychiatrists must be aware of this complication of treatment.

     
  17. Psychosis Following Left Thalamic Stroke
    Presenting Author:  Samuel Sostre
    Co-Author:  Gily Chechel

    Purpose: The emergence of psychosis in an older patient with no psychiatric history should prompt a search for secondary causes. Work-up generally includes neuroimaging to rule out strokes, among others, as being causative. The thalamus has a central role in behavior and cognition, and strokes in this region are associated with "cortical" syndromes and psychosis. Our goal is to draw attention to thalamic strokes as a possible cause of new onset psychosis.

    Methods: We present a case of acute onset psychosis and cognitive deficits encountered on our consultation service. We will discuss "cortical syndromes" after thalamic strokes, and how these can mimic primary psychiatric illnesses.

    Results: A 62 year-old female with hypertension, diabetes mellitus and hyperlipidemia was admitted for disorientation and DKA. Psychiatric consultation was requested for paranoia and agitation after DKA resolved. The patient did not have any personal or family history of mental illness but was described by her husband as always being distrustful of others. On examination, she was alert, irritable and hostile, with pervasive, bizarre delusions of persecution. She denied any affective symptoms or hallucinations. During the hospital course her agitation and behavior improved, however she remained paranoid, did not recognize the psychiatric consultant despite daily visits, and frequently confabulated. Her Mini Mental State Examination score was 17/30, with poor orientation, recall and executive functioning, and intact attention. Medical workup was negative with the exception of neuroimaging, which revealed an acute left thalamic infarct and chronic white matter microvascular ischemic changes.

    Conclusions: The thalamus has a central anatomic position in the brain, receiving input and output from cortical and brain stem regions, thereby playing a crucial role in behavior and cognition. After thalamic strokes, patients can experience mania, psychosis and personality changes, which may mimic primary psychiatric disorders. Cognitive symptoms include amnesia, decreased level of consciousness and confabulation, and are easily confused with delirium. The pathogenesis of deficits is possibly due to decreased metabolic activity in distant brain structures communicating with the thalamus; a concept known as diaschisis. This case report hopes to make consultation psychiatrists aware of this known, but rare, post stroke syndrome.

    References:

    1. Arikan MK, et al: A case of psychosis associated with left thalamic lacunar infarcts. Prog Neuropsychopharmacol Biol Psychiatry 2009; 33(4):729-30.

    2. Bogousslavsky J, et al: Manic delirium and frontal-like syndrome with paramedian infarction of the right thalamus. J Neurol Neurosurg Psychiatry 1988; 51(1):116-9.

    3. Carrera E, Bogousslavsky J: The thalamus and behavior: effects of anatomically distinct strokes. Neurology 2006; 66(12):1817-23.

    4. Ghika-Schmid F, Bogousslavsky J: The acute behavioral syndrome of anterior thalamic infarction: a prospective study of 12 cases. Ann Neurol 2000; 48(2):220-7.

    5. McGilchrist I, et al: Thalamo-frontal psychosis. Br J Psychiatry 1993; 163:113-5.

    Objectives:

    1. Understand that thalamic strokes can present with psychosis.
    2. Explore the role of the thalamus in cognition and behavior.
    3. Identify behavioral syndromes based on anatomic location of stroke within the thalamus.

    Relevance:
    Psychosomatic medicine psychiatrists frequently encounter patients who present with atypical psychiatric features. This case report hopes to make consultation psychiatrists aware of this known, but rare, post stroke syndrome.

     
  18. [T] Management of Psychiatric Symptoms in Anti-NMDAR Encephalitis: A Case Series and Literature Review
    Presenting Author:  Christopher Takala
    Co-Authors:  Preetha Kuppuswamy, Christopher Sola

    Anti-NMDA receptor (NMDAR) encephalitis, formally recognized in 2007, has been increasingly identified as a significant cause of autoimmune and paraneoplastic encephalitis. The exact incidence is unknown. Approximately 80% of the patients are females. The characteristic syndrome evolves in several stages, with approximately 70% of the patients presenting with a prodromal phase of fever, malaise, headache, upper respiratory tract symptoms, nausea, vomiting and diarrhoea. Next, typically within two weeks, patients develop psychiatric symptoms including insomnia, delusions, hyperreligiosity, paranoia, hallucinations, apathy and depression. Catatonic symptoms, seizures, abnormal movements, autonomic instability, and memory deficits may also develop during the course of the disease. Presence of antibodies against the GluN1 subunit of the NMDAR in the CSF and serum confirm the diagnosis of NMDAR encephalitis, which also should prompt a thorough search for an underlying tumor. Age, gender, and ethnicity may all play a role, as black females older than 18 years of age have an increased likelihood of an underlying tumor. Treatment is focused on tumor resection and first-line immunotherapy (corticosteroids, plasma exchange, and intravenous immunoglobulin). In non-responders, second-line immunotherapy (rituximab or cyclophosphamide or combined) is required. More than 75% of the patients recover completely or have mild sequelae, while the remaining patients end up demonstrating persistent severe disability or death.

    There is a paucity of literature on the management of psychiatric symptoms in this population. Given the neuropsychiatric symptoms in the relatively early phase of the illness, approximately 77 % of the patients are first evaluated by a psychiatrist. Earlier recognition of this illness is of paramount importance as prompt diagnosis and treatment can potentially improve prognosis.

    We describe two patients diagnosed with NMDAR encephalitis presenting with two different psychiatric manifestations. The first patient presented with psychotic mania and catatonic symptoms, while the second suffered from depression with psychotic and catatonic features refractory to psychotropic medications. We review of the use of psychotropic medications and ECT to address insomnia, agitation, psychosis, mood dysregulation and catatonia in NMDAR encephalitis.

    Objectives:

    1. To recognize the varied psychiatric manifestations in anti-NMDAR encephalitis.
    2. To learn about the use of various psychotropic medications for treatment in this disorder.
    3. To learn about the use of electroconvulsive therapy for treatment of catonic symptoms.

    Relevance:
    The early phases of this disease manifests with a variety of neuropsychiatric symptoms. Clinicians, especially psychiatrists, should be aware of this disease to avoid misdiagnosis and delay in treatment.

     
  19. [T] Delusional Parasitosis Secondary to Peripheral Neuropathy and Cognitive Impairment Treated with Gabapentin: A Case Report
    Presenting Author:  Paul Thisayakorn
    Co-Author:  James Amos

    Purpose: Delusional parasitosis is a rare psychiatric condition. It can be classified as primary (delusional disorder, somatic type) and secondary (induced by medical conditions, drug effects, or psychiatric illnesses). We report a case of delusional parasitosis as a presenting symptom of peripheral neuropathy and cognitive impairment.

    Method: We reviewed the clinical charts from several settings at the University of Iowa Hospitals from January 2011 to January 2013. The demographic data, clinical presentation, laboratory results, nerve conduction study, brain imaging, and management plan are described.

    Result: This 71-year-old widowed Caucasian female gradually developed a delusion of infestation over a 6-month period. She had been depressed in the past 3 years after her husband passed away. She also had hypertension, osteoporosis, and COPD. She described the sensation of something crawling and biting the skin on her legs at night. She believed there was a group of mice or bugs in her trailer house. She called a vermin control service, but they were unable to find any objective evidence of infestation.

    She had been irritable, anxious, and dysphoric with labile affect. She reported progressive impairment in concentration and memory. Further examination revealed hammer toes and high arch feet with decreased soft touch and vibratory sense. Laboratory investigations were unremarkable. A nerve conduction study reported predominantly axonal sensorimotor polyneuropathy. Her brain MRI showed mild parenchymal volume loss with evidence of small vessel ischemic disease in a deep white matter periventricular distribution. Neuropsychological assessment demonstrated cognitive deficits consistent with multifocal brain dysfunction, particularly in the frontal lobes. She had limited insight into the psychiatric interpretation of her presentation but accepted the suggestion of peripheral neuropathy causing the crawling sensation. She refused to take antipsychotic after trying a few doses of 0.5 mg risperdal. Her depression had been better controlled with paroxetine 20 mg. Interestingly, she reported improvement of the bug crawling sensation shortly after gabapentin was added to her regimen. It was titrated up to 600 mg twice/day.

    Conclusion: We describe a case of delusional parasitosis as a presenting symptom of peripheral neuropathy and cognitive impairment. This case emphasizes the importance of exploring possible organic causes before diagnosing primary somatic delusional disorder. We also highlight the benefit of nerve conduction studies, brain imaging, and neuropsychological assessment as important tools for elucidating the etiologies of the delusion in this case. Moreover, her symptoms were temporarily alleviated by gabapentin. This medication may be an appropriate augmenting agent to antipsychotic in some cases.

    Objectives:

    1. The importance of exploring possible organic causes before diagnosing primary somatic delusional disorder.
    2. Highlight the benefit of nerve conduction studies, brain imaging, and neuropsychological assessment as important tools for elucidating the etiologies of the delusion.
    3. Gabapentin as a possible augmenting agent to antipsychotic in some delusional parasitosis cases.

    Relevance:
    Delusional parasitosis is a rare psychiatric condition. Psychosomatic medicine physicians play a major role in diagnosing and managing this illness.

     
  20. [T] Central Pontine Myelinolysis (CPM): A Serious Consequence of Chronic Alcoholism
    Presenting Author:  Priya Vaidya Shrestha
    Co-Author:  Aasia Syed

    Introduction: Alcohol may induce damage to the central and peripheral nervous system as a result of direct damage or via breakdown products like acetaldehyde resulting into myelin degeneration. Adams et al in 1959 described Central Pontine Myelinolysis as a disease affecting chronic alcoholics and the malnourished manifested clinically as pseudobulbar palsy and quadriplegia leading to death.

    Method: Case report. A 40 year old male with history of chronic alcoholic cirrhosis presented initially with jaundice, upper GI bleed & dark, tarry stools. He was found to have multiple ongoing medical problems. The patient on admission had dehydration and severe hyponatremia which was initially corrected. During hospitalization, he developed altered mental status. Neurology was consulted: he had bilateral facial nerve palsy upper motor neuron type, dysarthria and quadriparesis. MRI showed osmotic demyelination in the pons area. CPM was diagnosed. Upon review, it was noted that the hyponatremia had been corrected gradually but he still developed CPM. His mental status improved gradually. There was only some improvement in dysarthria and quadriparesis and he was discharged to skilled nursing facility.

    Discussion: CPM is a rare neurological disease caused by severe damage to the myelin sheath of nerve cells in the pons area due to osmotic injury to the vascular endothelial cells causing release of myelinotoxic factors [2]. It can cause acute paralysis, dysphagia, dysarthria, and other neurological symptoms. It is commonly seen in chronic alcoholism, hyponatremia, severe liver disease, malnutrition, severe burns, liver transplant, anorexia etc.

    Yoon et al reported a case in which CPM developed in a chronic alcoholic during alcohol withdrawal despite slow correction of hyponatremia [2]. Chang et al suggested that acute liver dysfunction may be linked to development of CPM [3]. Our patient had multiple possible contributing factors for CPM - chronic alcoholism, hyponatremia and liver cirrhosis.

    In conclusion, CPM can be a very serious consequence of chronic alcoholism. Rate of correction of hyponatremia may not always correlate with the development of CPM (4). Other co-morbid factors may increase the risk of developing CPM. Psychiatrist should be vigilant about the possibility of CPM when treating chronic alcoholics with co-morbidities.

    References:

    1. Adams RD, Victor M, Mancall EL: Central pontine myelinolysis: a hitherto undescribed disease occurring in alcoholic and malnourished patients. Arch Neurol Psychiatry 1959; 81:778-780.

    2. Yoon B, Shim YS, Chung SW: Central pontine and extra pontine myelinosis after alcohol withdrawal. Alcohol Alcohol 2008; 43(6):647-9.

    3. Chang Y, An DH,Xing Y, Qi X: Central pontine and extrapontine myelinosis associated with acute hepatic dysfuntion. Neuro Sci 2012; 33(3):673-6.

    4. Shah SO, Wang A, Mudambi L, Ghuznavi N, et al: Asymptomatic central pontine myelinosis: a case report. Case Rep Neurol 2012; 4(3):167-72.

    Objectives:

    1. Central pontine myelinolysis as a serious complication of chronic alcoholism.
    2. Central pontine myelinolysis occurs despite gradual correction of hyponatremia.
    3. Central pontine myelinolysis occuring because of acute hepatitis

    Relevance:
    It is important to realize that CPM is a possibly rare but serious complication of chronic myelinolysis. For psychiatrists it is important to recognize neurological symptoms, monitor sodium, and keep in mind the comorbidities.

     
  21. Marchiafava-Bignami Disease (MBD): A Radiologically Identifiable Cause of White Matter Cortical Degeneration Presenting as Cognitive Impairment
    Presenting Author:  Mitzi Wasserstein
    Co-Authors:  Thomas Beresford, Adam Chin, Abby Ornelos-Lozano

    Cortical white matter degeneration frequently presents among inpatients seen in the consultaion-liaison psychiatry setting and is often difficult to assess with respect to clinical presentation. The corpus callosum, rich in concentrated myelin of the neural sheaths that connect the two cerebral hemispheres, provides a radiographic structure for white matter assessment. Among the syndromes that can affect callosal myelin degeneration, alcohol-related Marchiafava-Bignami disease (MBD) affords some radiologic specificity in its characteristic lesion in the genu of the corpus. Because of this, correlation with associated cognitive impairment may be particularly useful in characterizing the clinical presentation of MBD that is often diagnosed only with brain MRI. We present a case of cognitive impairment in association with MBD, along with brain MRI imaging verifying MBD. We review our hospital's experience with MBD over the past 5 years, noting the occurrence of this relatively rare condition, and present other conditions in the differential diagnosis, such as chronic inflammatory demyelinating polyneuropathy (CIDP). This review suggests that MBD is likely one extreme version of callosal degeneration seen frequently in association with heavy alcohol use and the clinical presentation of non-Korsakoff cognitive impairment.

    Objectives:

    1. Recognize Marchiafava-Bignami disease as a cause of non-Korsakoff cognitive impairment.
    2. Understand the differential diagnosis of corpus callosal degeneration.
    3. Consider Marchiafava-Bignami disease in patients presenting with significant histories of alcohol use or dependence and non-Korsakoff cognitive impairment.

    Relevance:
    Consultation-liaison psychiatrists frequently see cognitive impairment in patients with a long history of alcohol abuse or dependence. This presentation will expand the differential diagnosis to include Marchiafava-Bignami disease.

     
  22. [T] Catatonia Caseness: Defining an Elusive Condition
    Presenting Author:  Jo Ellen Wilson
    Co-Author:  Stephan Heckers

    Purpose: Catatonia is an important and diverse neuropsychiatric syndrome, which consists of psychological and motoric signs, can be evidenced by hypokinesis, hyperkinesis or both, as well as volitional signs [1]. In its most severe form death can result in 10% of all cases. The incidence of catatonia has ranged from 2.7-12% in the inpatient psychiatric setting [2]. Incidence of catatonia on a psychiatric liaison service was 1.6% across medical services, with percentages being as high as 20% on inpatient Neurology services [3,4]. Despite the frequency of presentation of catatonia in both the general medical and psychiatric populations, it remains poorly understood and frequently undiagnosed, leading to increased morbidity and mortality. Several catatonia rating scales exist, consisting of 10 to 40 signs. The Bush Francis Catatonia Rating Scale is the most widely used in the clinical setting, given its ease of use, as well as its high validity and reliability [5]. Despite its wide use, little research has gone into understanding which catatonic signs are essential to the diagnosis or caseness of catatonia. In this study we attempt to distinguish essential from nonessential signs of catatonia in order to further define the disorder and simplify examination.

    Methods: We retrospectively reviewed the charts of 273 medically and psychiatrically admitted patients with a Bush Francis Catatonia Rating Scale (BFCRS) on file. Patients were considered to meet diagnostic criteria for catatonia if they scored positively on at least 2 of the first 14 items of the scale.

    Statistical analyses are ongoing.

    Results: Of the 23 items listed in the BFCRS, staring was the most frequently represented (78.57%), followed by immobility/stupor (64.71%), with combativeness being the least represented (12.18%). Interestingly, if excitement was removed from the examination criteria 12.96% would no longer meet diagnostic criteria (caseness) despite this being present in 22.69% of the study population. The criterion least likely to affect caseness was grimacing (only 1.75% of cases would be voided if this criterion were removed.)

    Final results are pending as data analyses are ongoing.

    Conclusions: Final conclusions are pending final statistical analyses.

    References:

    1. Peralta V, Campos MS, Garcia de Jalon E, Cuesta MJ: DSM-IV catatonia signs and criteria in first-episode, drug-naïve, psychotic patients: psychometric validity and response to antipsychotic medication. Schizophr Res 2010; 118(1-3):168-75.

    2. Francis A: Catatonia: diagnosis, clarification and treatment. Curr Psychiatry Rep 2010; 12(3):180-185.

    3. Barnes MP, Saunders M, Walls TJ, Saunders I, Kirk CA: The syndrome of Karl Ludwig Kahlbaum. J Neurol Neurosurg Psychiatry 1986; 49(9):991-996.

    4. Carroll BT: Catatonia on the consultation-liaison service. Psychosomatics 1992; 33(3):310-315.

    5. Sienaert P, Rooseleer J, De Fruyt J: Measuring catatonia: a systematic review of rating scales. J Affect Disord 2011; 135(1-3):1-9.

    Objectives:

    1. Understand the importance of recognizing and treating catatonia in the medical population.
    2. Understand which catatonia signs are essential versus nonessential to the diagnosis of catatonia.
    3. Understand how the diagnostic criteria for catatonia have evolved from DSM-IV-TR to DSM-V.

    Relevance:
    Catatonia is a neuropsychiatric disorder frequently observed in the psychosomatic population, but often times under diagnosed. This presentation will suggest which catatonia signs are essential to the caseness of catatonia.

     
  23. Testing the Use of Standardized Scripts for Disclosing "Hypothetical/Mock" Amyloid PET Scan Results to Nondemented Cognitively Impaired Patients and Their Care Partners
    Presenting Author:  Michael Witte
    Co-Authors:  Janet Barnes, Jennifer Lingler, Marc Agronin, Helen Hochstetler, Kristine Healey, Ann Hake, Paula Trzepacz

    Background: With the FDA's approval of florbetapir F18 injection (Amyvid), the first commercially available diagnostic PET tracer for the estimation of beta-amyloid neuritic plaque density in the living brain, patients with cognitive decline will be scanned in increasing numbers in the clinical setting. It is critically important to identify effective approaches for communicating brain scan results to patients and their care partners (CP). Disclosing amyloid imaging results is complicated by the fact that although these scans are designed to detect AD pathology in vivo, they are intended as an adjunct to, not a substitute for, a clinical dementia evaluation. While scans could be especially informative for patients with mild cognitive impairment (MCI), deficits in memory and language may make it difficult for individuals with MCI to understand the information that they receive during a feedback session. Currently, there is no standardized method of disclosing amyloid scan results to cognitive impaired patients and little understanding of how to measure patient understanding of the disclosed scan results. This qualitative study evaluated patient and CP understanding of "hypothetical" amyloid PET scan results in a mock clinical setting using professional [nonphysician] interviewers.

    Methods: Standardized scripts describing the purpose of amyloid imaging (florbetapir F 18 PET) and results for positive and negative scans were tested and refined using input from 2 neurologists, 2 internists and 2 psychiatrists. We performed "mock" clinical interviews with a demographically diverse sample of 13 patient (older adults with cognitive complaints or mild cognitive impairment) and CP (adult child, spouse, sibling, other) dyads and 11 CPs. Standardized scripts were used for pre-scan explanation and result disclosure. A semi-structured interview of the patient followed by CP assessed level of understanding, rated by consensus of observers.

    Results: Among the 13 dyads, the patients' mean age was 71.2 years (range: 49-90) and the majority were Caucasian (69.2%). The pre-scan and results dialogues were understood by CPs regardless of demographic backgrounds. Patients' understanding was lower than CPs', which generally varied by their cognitive ability. Scientific terminology needed simplified explanations. Despite carefully distinguishing that PET evidence of amyloid was not synonymous with a clinical diagnosis of Alzheimer's disease, this relationship was still presumed by the recipients. CPs and patients generally accepted the disclosure of mock positive results with a range of emotional responses but immediately wanted to hear a treatment plan; they expressed relief from a negative result and indicated a desire for more information regarding possible other reasons for the patient's cognitive impairment. Patients and CPs requested written take-home information.

    Conclusions: Our findings suggest that standardized information about amyloid PET imaging can be effectively communicated to patients with MCI and their care partners. Take-home information and expeditious treatment planning are important parts of that process.

    Objectives:

    1. Appreciate that care partners of MCI patients understand simple clinical explanations for purpose and hypothetical results of florbetapir F18 PET scan when tested in a mock clinical situation.
    2. Understand that the patient’s ability to understand florbetapir F18 PET scan when tested in a mock clinical situation can be limited by the severity of their MCI.
    3. Learn that MCI patients and their care partners are eager to engage in treatment planning and management regardless of hypothetical result of the florbetapir F18 PET.

    Relevance:
    To inform the development of a best practice for effectively communicating amyloid imaging scan results to patients and families affected by mild cognitive impairment.

     

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Section E:  Pediatrics and Women's Health

  1. [T] Psychotic Denial of Pregnancy: A Case Report and Review of Literature
    Presenting Author:  Md. Ashik Ansar
    Co-Author:  Carolina Retamero

    Background: Psychotic denial of pregnancy is an important condition that is more common than expected; however, only a few case reports and review of literature have been published. This denial in chronic mentally ill women may place the women and their fetuses at high risk of postpartum emotional disturbance, precipitous or unassisted delivery, fetal abuse, and neonaticide. We report the challenging case of a psychotic patient presenting with denial of pregnancy, who previously had presented with delusion of being pregnant in her early disease course.

    Case report: A 26 year old African American, single, unmarried women, with past history of schizophrenia was referred to inpatient psychiatry unit at 24 weeks of gestation. Patient was overtly psychotic with disorganized behavior, paranoid, responding to internal stimuli and thought blocking. She was consistently denying her current pregnancy despite the confirmatory test results.

    The patient was first diagnosed schizophrenia at her age 17, in next 3 years she visited twice to that psychiatry service and presented similarly being delusional on both occasions claiming that she was pregnant. Fifteen months later, she became pregnant for the first time but unfortunately lost that pregnancy at 24 weeks of gestation. In next 4 years she became a mother of 2 children, however lost the custody of her children through the Department of Human Services (DHS).

    Methods: A review of the literature and PubMed search was conducted using key words: "pregnancy", "denial"', "psychotic denial", "non-psychotic denial".

    Discussion: Psychotic denial or denial of external reality is one of the most pathological and immature defense mechanisms that may be associated with unbearable loss [1]. Our patient's initial psychotic episodes with delusional thoughts that she was pregnant could have come from her unconscious desire to become a mother meaningfully connect to the society. Her current psychotic denial of pregnancy [2] we believe, may relate to her unresolved grief with inadequate coping resulting from previous experiences with fetal demise [3] or psychological conflict, such as intense wish to have a baby while fearing loss of the infant to DHS [4].

    References:

    1. Vaillant GE: Theoretical hierarchy of adaptive ego mechanisms. Arch Gen Psychiatry 1971; 24:107-118

    2. Miller LJ: Psychotic denial of pregnancy: phenomenology and clinical management. Hosp Community Psychiatry 1990; 41(11):1233-7.

    3. Leon IG: The psychoanalytic conceptualization of perinatal loss: a multidimensional model. Am J Psychiatry 1992; 149:1464-1472.

    4. Spielvogel AM, Hohener HC, et al: Denial of pregnancy: a review and case reports. Birth 1995; 22(4):220-226.

    Objectives:

    1. To identify clinical presentations on psychotic denial of pregnancy.
    2. To describe the psychodynamics of psychotic denial of pregnancy.
    3. To recognize the obstacles and challenges in managing psychotic denial of pregnancy.

    Relevance:
    Psychotic denial of pregnancy in the face of definite sign symptoms and positive test results has been considered a rare but potentially dangerous clinical condition. Its management is also challenging.

     
  2. [T] When to Involuntarily Commit in Anorexia Nervosa: A Case Report and Discussion
    Presenting Author:  Melanie Barrett
    Co-Authors:  Sheryl Fleisch, Jennifer Richards, Maria La Via, Elena Perea

    Purpose: The lifetime prevalence of anorexia nervosa (AN) in females is estimated to be 0.9% [1]. Although relatively rare, patients with AN have a high mortality rate with a standardized mortality ratio of 5.86 with up to 20% of deaths being secondary to suicide [2]. Approximately 46% of individuals treated for AN recover fully, with another third showing partial recovery; however, physicians often encounter resistance when attempting to treat the underlying eating disorder [2]. We aim to use a case report to review the issue of involuntary commitment in an individual with AN.

    Methods: We review a case of a young adult female who was initially involuntarily committed to a psychiatric hospital for suicidality. While hospitalized, she was found to be significantly underweight with a BMI of 15. She exhibited marked bradycardia and hypotension. The treatment team observed food restriction and eating disorder cognitions related to body weight and beliefs about food. She was subsequently diagnosed with anorexia nervosa, restricting type. She lacked insight into her eating disorder, and both she and her family declined transfer to an inpatient eating disorders unit at the same psychiatric hospital. As the time of her involuntary commitment court hearing approached, the treatment team had to decide whether to release her from involuntary commitment, as she denied ongoing suicidality, or to pursue ongoing involuntary commitment based on the acute medical risk resulting from her diagnosis of AN. Using this case, in addition to a review of the literature, we discuss options for physicians when a patient with AN refuses treatment.

    Results: The patient in our case was initially admitted to the psychiatric hospital under involuntary commitment for suicidality. Prior to her commitment hearing, she adamantly denied suicidality, however, her risk to self secondary to her eating disorder symptoms became evident. Based on these concerns for acute medical risk, the treatment team proceeded with a commitment hearing.

    Conclusions: AN is a treatable disorder, with up to 46% of individuals achieving full recovery [2]. However, treatment recommendations are often met with resistance by the patient. Capacity assessments are done routinely for patients refusing treatment, but if a patient’s eating disorder places the individual at acute risk for death secondary to medical sequelae, involuntary commitment should be considered. Physicians should be aware of their state’s involuntary commitment (IVC) laws and consider whether or not an individual with AN who refuses treatment meets IVC criteria.

    References:

    1. Hudson JI, et al: The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatr 2007; 61(3):348–58.

    2. Arcelus J, Mitchell AJ, Wales J, Nielsen S: Mortality rates in patients with anorexia nervosa and other eating disorders: a meta-analysis of 36 studies. Arch Gen Psychiatry 2011; 68(7):724-31.

    Objectives:

    1. Review the concept of forced treatment in patients with AN.
    2. Discuss involuntary commitment in patients with AN who refuse treatment.
    3. Review available literature on involuntary commitment in patients with AN.

    Relevance:
    Consultation-liaison psychiatrists often assist in the care of patients with AN. We intend to discuss the difficult decision about involuntary commitment in individuals with AN who refuse treatment.

     
  3. Depression, Anxiety, and Quality of Life in Hospitalized High-Risk Obstetrical Patients
    Presenting Author:  Nancy Byatt
    Co-Authors:  Katherine Hicks-Courant, Autumn Davidson, Ruth Levesque, Gina Zarella, Eric Mick, Tiffany Moore Simas

    Introduction: There is a dearth of research examining the impact of obstetric hospitalization on depression, anxiety, and quality of life. The goals of this study were to assess the following among women hospitalized intrapartum due to high-risk pregnancies: (1) rates of depression and anxiety; and, (2) changes in depression and anxiety symptoms and quality of life.

    Methods: Sixty three subjects hospitalized due to high risk obstetrical complications were recruited between June 2011 and September 2012. Subjects completed the Edinburgh Postnatal Depression Scale (EPDS), Generalized Anxiety Disorder 7-item scale (GAD-7), and Short-Form 12 (SF-12) on a weekly basis and once postpartum.

    Results: Total average length of hospital stay was 8.3±7.6 days (1 survey); average stay among subsets was 25.4±10.2 (n=17; 3 surveys) and 35±10.9 days (n=9; 4 surveys). Seventeen women (26.9%) scored > 10 on the EPDS and 8 (12.6%) scored > 10 on the GAD-7. We did not find a significant change in depression (p=0.1) or anxiety (p=0.2) symptoms over the course of hospitalization. Quality of life significantly declined throughout hospitalization (p<0.001). Postpartum depression did not change significantly compared to depression at admission (7.0±5.6 vs. 4.4±5.7, p=0.1). Trends suggested lower anxiety (7.8±8.4 vs. 4.2±6.5, p=0.07) and reduced quality of life (30.1±2.3 vs. 28.3±3.2, p=0.052) postpartum.

    Conclusions: Our findings indicate higher rates of depression and anxiety in women hospitalized obstetrically than previously reported rates in non-hospitalized pregnant women. Quality of life may also decline during obstetric hospitalization. This suggests that depression and anxiety should be addressed during inpatient obstetrical care.

    Objectives:

    1. Discuss rates of depression and anxiety among women hospitalized intrapartum due to high risk pregnancies.
    2. Describe changes in depression and anxiety symptoms and quality of life that occur among women hospitalized intrapartum due to high-risk pregnancies.
    3. Identify ways in which depression and anxiety can be addressed during inpatient obstetrical care.

    Relevance:
    Perinatal depression and anxiety are common and have deleterious effects. It is critical to understand the rate/severity of depression and anxiety among women hospitalized due to high risk pregnancies.

     
  4. [T] Presenting Symptoms of Women with Depression in an Obstetrics-Gynecology Setting
    Presenting Author:  Joseph Cerimele
    Co-Authors:  Erik Vanderlip, Carmen Croicu, Jennifer Melville, Joan Russo, Susan Reed, Wayne Katon

    Objective: To describe the presenting symptoms of women with depression in two obstetrics-gynecology (Ob-Gyn) clinics, determine depression diagnosis frequency in this setting, and examine factors associated with a depression diagnosis.

    Methods: Data was extracted from charts of all participants screening positive for depression in a randomized, controlled trial testing whether a collaborative care depression intervention in improved clinical outcomes in women with depression. Bivariate and multivariable analyses examined patient factors associated with Ob-Gyn physician depression diagnosis.

    Results: Eleven percent of women with depression presented with a psychological chief complaint but another 30% had some mention of psychological distress. Approximately 40% of women with depression were diagnosed by their physician and recognition of affective illness did not increase with depression severity. Bivariate analyses showed that four factors were significantly associated with depression diagnosis: report of a psychological symptom as chief complaint or in chart notes (72% vs 18.6%, p<.001), younger age (35.5 vs. 40.8, p<.005), being within 12 months of delivery (13.9% vs. 2.8%, p<.005), and a primary care oriented Ob-Gyn visit (72% vs 30%, p<.001). Multivariable analysis showed that three variables remained significantly associated with a depression diagnosis: report of a psychological symptom (OR 8.90, 95% CI 4.15-19.10, p<.001), younger age (OR 0.96, 95% CI.93-.96, p=.021) and a primary care oriented Ob-Gyn visit (OR 2.46, 95% CI 1.14-5.29, p=.031).

    Conclusion: Women with depression in an Ob-Gyn clinic generally present with physical rather than depressive symptoms. Only a minority of women with depression were recognized as having depression and recognition was unrelated to severity.

    Objectives:

    1. To describe the presenting symptoms of women with depression in two obstetrics-gynecology (Ob-Gyn) clinics.
    2. To describe the frequency of Ob-Gyn physician depression diagnosis in two groups of patients with depression.
    3. To explore factors associated with an Ob-Gyn physician depression diagnosis.

    Relevance:
    Women with depression generally present with physical rather than depressive symptoms. Only a minority of women with depression were recognized as having depression.

     
  5. “We Heard That She Died”: Legends of a Pregnant Foreign Body Ingestor with Borderline Personality Disorder
    Presenting Author:  Syma Dar
    Co-Author:  Carrie Cichocki

    Purpose: Borderline personality disorder (BPD) is a challenge to manage in any setting. While challenges abound during a brief medical hospitalization, they are intensified during a lengthier hospitalization. Patients particularly struggle in dealing with hospital staff, with interpersonal issues plaguing medical care. We present a case of severe BPD with confounding factors (particularly foreign body ingestion) intensifying difficulty in management on a high-risk OB floor.

    Methods: A review of the literature revealed limited information regarding management of BPD during long-term hospitalization on a medical/OB floor.

    Background: TL was a 27 yo female at 30 weeks gestation admitted to a high risk OB floor with abdominal pain and pre-term labor. She had several medical admissions during pregnancy: pseudoseizures, EGD's for foreign body ingestion, and DVT. This was her lengthiest admission; she remained on the OB floor until after her c-section at ??? weeks. Over the years, TL had been diagnosed with every possible axis I disorder, and BPD. Her case was complicated by pregnancy, foreign body ingestion, a legal guardian, an Assertive Community Treatment (ACT) team, history of abuse, chemical dependency (opioids), estrangement from FOB, an atypical array of social support, and visits from community treatment providers.

    The foremost challenge for OB staff was TL's explosive, erratic episodes of belligerence. She required a sitter during hospitalization for fear of swallowing episode while pregnant. The OB staff culture of physical and emotional closeness with patients was counter-therapeutic.

    Results: With our instruction, TL's OB care was successful despite her many psychiatric issues. Interventions included educating staff about BPD, tempering expectations of TL, equipping staff with behavioral techniques, and basic limit-setting. C-L staff provided psychoeducation via daily rounds, during weekly nursing meetings, conferences with specialty providers, as well as during treatment team meetings with TL's outpatient providers. TL was eventually treated with medications (olanzapine, mirtazapine, clonazepam, zolpidem).

    Conclusions: The combination of medication and extensive staff education and support allowed for some improvement in the frequency and severity of TL's belligerence episodes, and ultimately a safe and successful delivery. TL had no episodes of swallowing during this admission. The interdisciplinary, educational approach taken by the psychiatric C-L team allowed for a positive outcome and a surprisingly strong therapeutic alliance between psychiatry and the patient.

    Reference:

    1. Gitlin D, Caplan J, Rogers M, Avni-Barron O, Bruan I, Barsky A: Foreign-body ingestion in patients with personality disorders. Psychosomatics 2007; 48(2):162-166.

    Objectives:

    1. To share a unique and complex case involving the treatment of a patient with borderline personality disorder and foreign body ingestion undergiong treatment on the high risk OB floor.
    2. To learn treatment strategies and interdisciplinary efforts shown to be successful in this patient's treatment.
    3. To highlight the unique challenges faced in treating this particular patient in reviewing the available literature.

    Relevance:
    This poster shares the interdisciplinary techniques utilized in treating a patient with severe borderline personality disorder, foreign body ingestion, and substance abuse, while admitted to a high-risk OB floor.

     
  6. Impact of Shared Medical Appointments in Women with Depression and Anxiety
    Presenting Author:  Lilian Gonsalves
    Co-Authors:  Jerilyn Hagan-Sowell, Yvonne Chasser

    Purpose: Shared medical appointments (SMAs), also known as group visits, have become a useful vehicle in providing easier access to the physician with increased efficiency. The purpose of this paper is to evaluate the impact of SMAs on depression and anxiety as measured by the Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7).

    Methodology: In 2003, the Department of Psychiatry & Psychology at the Cleveland Clinic created a 90-minute group appointment for medication management. The participants were women with the diagnosis of depression and/or anxiety. Each participant filled out several screening tools, including the PHQ-9 and GAD-7. In 2012, 58 patients completed the PHQ-9 and GAD-7 during their first group appointment and at their last follow-up visit. The results were compared.

    Results: Overall, depression and anxiety symptoms were improved. A decrease in PHQ-9 and GAD-7 scores were noted in 64 % and 53% of patients respectively.

    Conclusion: SMAs are an efficient method of delivering quality care to patients and have a positive effect on the improvement of depression and anxiety as defined by the PHQ-9 and GAD-7.

    Objectives:

    1. Learn about the use of SMAs for depression and anxiety.
    2. Analyze outcome data for patients with mood and anxiety disorders.
    3. Increase efficiency and productivity in your outpatient practice.

    Relevance:
    Given the changes in health care next year, the SMA model will help providers see more patients efficiently and with easier access.

     
  7. [T] Is My Baby Going to Be Okay? A Review of Fetal Outcomes after Maternal Overdose
    Presenting Author:  Dylan Kathol
    Co-Authors:  Nathaniel Barusch, Daniel Hosker, Ian Steele, Jason Caplan

    Purpose: Although there appears to be a protective effect of pregnancy on suicide, maternal suicide is one of the leading causes of maternal mortality in the United States. Evidence indicates that for pregnant women death by suicide is second only to death caused by domestic violence. Over half of suicide attempts during pregnancy occur during the first trimester and the overwhelming majority of these attempts are by overdose. The purpose of this review is to examine literature on the effect of maternal suicide attempts on fetal outcomes.

    Method: A literature review using PubMed was conducted. Key terms were "Pregnancy;" "Overdose;" "Suicide, Attempts;" and "Birth outcomes."

    Results: Studies of fetal outcomes demonstrate mixed results, with the timing and method of poisoning playing a significant role. A retrospective analysis of maternal poisoning in California demonstrated that neonates were more likely to experience respiratory distress syndrome and LBW than control groups. There was an increased risk of preterm labor in the mothers of the neonates. Other studies found a high rate of very early fetal loss (i.e., positive pregnancy test without later clinical evidence of pregnancy) if poisonings occurred in the first three months, but there is no evidence that neonates that make it past this period are at increased risk for congenital abnormalities (CA).

    Nonetheless, there have been a limited number of drug-specific effects on the fetus detailed in case reports. Acetaminophen overdose, the most commonly used drug in overdose, can cross the placenta and may cause fetal hepatic necrosis and fetal demise. With benzodiazepine overdose, the drugs and their metabolites freely cross the placenta and levels may remain high in the fetus for much longer periods than in the mother. In two Hungarian studies of women who attempted suicide with alprazolam and diazepam in the first trimester, there was a high rate of very early fetal loss. However, of the live births in these women, the rates of CA did not significantly differ from control groups.

    Conclusions: Maternal overdose during the first trimester is associated with an increased risk of very early fetal loss. Some have hypothesized that this may be the result of an "all or nothing" effect during this critical period. Furthermore, the neonates born after such events may be at increased risk for prematurity, low birth weight births, and respiratory distress. Large population-based studies have not identified an association with CA, but there have been a limited number of studies examining specific drug effects.

    Objectives:

    1. Define the mechanisms of suicide most commonly used by pregnant women.
    2. Explain the potential for adverse fetal effects entailed by different types of overdose.
    3. Apply the available data to clinical situations in which a pregnant woman attempts suicide and is later concerned about the welfare of the fetus.

    Relevance:
    Concern for the wellbeing of the fetus is often a focal issue in the care of a pregnant woman who has attempted suicide. Here, we review the available evidence base.

     
  8. Prenatal Mental Health Treatment and Pregnancy Outcome
    Presenting Author:  Stephanie Kohler-Neuwirth
    Co-Author:  Christina Wichman

    In collaboration with the Department of Psychiatry and Obstetrics/Gynecology, a co-located perinatal psychiatry consult clinic was initiated in January 2010 for consultation on treatment of women with possible perinatal mental illness. Pregnant women are routinely screened for active symptoms of depression on their first prenatal visit using the Edinburgh Postnatal Depression Screen (EPDS); it is recommended that all women receiving a score of 11 or greater are referred to the perinatal psychiatry consult clinic. The standard of care within our clinic also includes EPDS screening at week 28 and at the 6-week post-partum visit. The aim of this study is to determine the prevalence of utilization of on-site perinatal psychiatric consultation services after a score of 11 or greater on the EPDS or patient referral at obstetrician's discretion for another reason. Additionally, we hope to establish whether there is a difference in obstetrical outcomes (preterm delivery, birth weight, and APGAR scores) and maternal psychiatric outcomes (hospitalization/suicide attempt) between pregnant women who engage in psychiatric services and those who do not. Previous research has indicated that untreated depression during pregnancy may carry with it an increased risk of preterm delivery and low birth weight.

    Methods: For the purpose of this study, we reviewed the medical records of three different groups of pregnant women treated in the general OB/GYN clinic over one year spanning from January 1, 2010 – December 31, 2010. These groups are:

    1. Pregnant women with an EPDS of 11 or greater seen in the perinatal psychiatry clinic and/or those referred to the clinic for another reason.

    2. Pregnant women with an EPDS of 11 or greater and/or who were referred to the perinatal clinic and did not follow through with referral.

    3. Pregnant women with an EPDS of 10 or lower who are not seen in the perinatal psychiatry clinic (control group).

    Only medical records from the time of pregnancy of these women up to the 6-week post-partum visit were reviewed. Demographic data, information about pregnancy complications, and information about psychiatric outcomes, including maternal psychiatric hospitalization and suicide attempts/completed suicide during pregnancy or in the post-partum period to 6 weeks post-partum, was recorded in a confidential research database. Data on pregnancy outcomes, including birth weight, weeks of gestation at delivery, and APGAR scores was identified by review of the neonatal charts linked to each subject in the medical record, and was also collected in the confidential research database. IRB approval was obtained.

    Results: We are currently in the process of reviewing all of the medical records at this time; we anticipate that data collection should be completed in June 2013 and statistical analysis in September 2013, allowing us to present full data in November 2013.

    Objectives:

    1. Describe the creation of a new outpatient co-located perinatal psychiatry consult service.
    2. Describe the utilization of psychiatric services by several different groups of pregnant women based on EPDS score and provider referral.
    3. Describe the differences of obstetrical outcomes between different groups of pregnant women based on EPDS score and provider referral.

    Relevance:
    Perinatal depression is a well-known complication of pregnancy; providers need to be aware of obstetrical and psychiatric outcomes related to presence of a co-located perinatal psychiatric clinic.

     
  9. WITHDRAWN
     
  10. The Path from Childhood Maltreatment to Somatic Symptoms: Defining the Mediators
    Presenting Author:  David Lovas
    Co-Author:  Martin Teicher

    Purpose: There is a well-established association between childhood maltreatment and several of the most common, but poorly understood, disorders that meet at the intersection of medicine and psychiatry: somatoform disorders, medically unexplained physical symptoms, and functional disorders. In spite of the evidence supporting this association, there is a paucity of research aimed at elucidating the factors mediating the relationship between maltreatment and somatic symptoms. The current study aimed to analyze this relationship and potential mediators in a large community sample of young adults.

    Method: A community sample of unmedicated, young adults (n=2041; 61.5% female; 22.0±2.3 years of age) were assessed by self report for childhood maltreatment (physical, verbal, or sexual abuse; witnessing of domestic violence; peer bullying), medical history, and sociodemographic factors. Self-report rating scales were used to assess levels of depressive, anxiety, anger-hostility, dissociation, "limbic irritability," and somatic symptoms, and the quality of the parental relationship. Path analysis (R package OpenMx) was used to evaluate structural equation models (SEM) showing the interrelationship between exposure to maltreatment and ratings of somatic symptoms, with the inclusion of the above ratings of symptoms, parental bonding, sociodemographic factors, and medical history as potential mediating factors. Separate models were conducted for each gender, given the evidence of significant gender differences in somatic symptoms.

    Results: Path analyses indicated that the female and male models were both good fits to their respective data. In both models, childhood maltreatment had no direct relationship with somatic symptoms. The relationship was completely explained by other factors. Common mediators shared by the female and male models included "limbic irritability," anxiety, depressive, and anger-hostility symptoms, and medical illness. Dissociation was not significant in the female model, and had a small negative relationship with somatic symptoms in the male model. Maternal caring had a negative relationship with maltreatment and psychiatric symptoms in the female model. No parental factors were significant in the male model. Sociodemographic factors were not significant in either model. The mediators in the female and male models explained 91% and 99% of the variance in somatic symptoms respectively.

    Conclusion: An array of neuropsychiatric symptoms, and, to a lesser extent, a history of medical illness, appear to fully mediate the relationship between childhood maltreatment and somatic symptoms in a large community sample of relatively healthy young adults. This finding will need to be replicated in clinical populations and other age groups. While SEM cannot prove causality in cross-sectional data, the present findings highlight potential targets for prevention or intervention, and shed more light on the complex path from maltreatment to somatic symptoms.

    Reference:

    1. Roelofs K, Spinhoven P: Trauma and medically unexplained symptoms towards an integration of cognitive and neuro-biological accounts. Clin Psychol Rev 2007; 27:798-820.

    Objectives:

    1. Describe the role of childhood maltreatment in the development of medical disease, psychiatric disorder, and somatic symptoms of unspecified origin.
    2. Identify some of the key factors that mediate the relationship between childhood maltreatment and somatic symptoms.
    3. Consider further directions for basic and clinical research, as well as implications for prevention and treatment in this area.

    Relevance:
    Childhood maltreatment is common in the community, and is an important risk factor for a wide array of medical and psychiatric conditions that are commonly seen by C-L psychiatrists.

     
  11. [T] Chronic Pelvic Pain and Somatoform Disorders: A Case of a Woman with Non-Epileptic Seizures
    Presenting Author:  Margaret May
    Co-Authors:  Yelizaveta Sher, Nadia Haddad, Jose Maldonado

    Purpose: The relationship between chronic pain disorders and psychiatric conditions such as anxiety, depression, and somatoform disorders is of interest to clinicians, but research specifically about pelvic pain disorders is lacking. It is estimated that around 7% of the general population suffers from chronic pelvic pain. While some presentations of chronic pelvic pain have a known etiology, such as endometriosis, other presentations lack an obvious cause and fall under the rubric of medically unexplained symptoms. This case explores the potential relationship between chronic pelvic pain and somatoform disorders, specifically conversion disorder as manifested by a non-epileptic seizure disorder.

    Methods: Case Presentation and Literature Review

    Results: The patient is a 56 year old woman who presented to the neurology inpatient service for evaluation of her seizures that started seven years ago and now occurred daily. Video monitored continuous EEG enabled diagnosis of a non-epileptic seizure disorder and the patient was transferred to the psychiatric inpatient unit voluntarily to explore the role of stressors. Her history was also notable for chronic, unexplained pelvic pain that started in her late teens and resulted in an exploratory laparotomy at age 20, with a subsequent hysterectomy at age 22 for "pelvic adhesions." Her medical and psychosocial history following this event included onset of panic attacks, chronic nausea and vomiting, and other symptoms suggestive of somatic manifestations of psychiatric disease. During her time on the inpatient psychiatry unit, she eventually revealed a history of ongoing abuse in her home.

    Discussion: Unexplained pelvic pain may be a risk factor for development of somatoform disorders; however the relationship is not yet known and deserves further study. Several potential relationships and mechanisms have been proposed and are explored in this case study.

    References:

    1. Latthe P, et al: WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity. BMC Public Health 2006; 6:177-93.

    2. Champaneria R, et al: Psychological therapies for chronic pelvic pain: systematic review of randomized controlled trials. Acta Obstet Gynecol Scand 2012; 91.

    3. olde Hartman TC, Borghuis MS, Lucassen PL, van de Laar FA, Speckens AE, van Weel C: Medically unexplained symptoms, somatisation disorder and hypochondriasis: course and prognosis. A systematic review. J Psychosom Res 2009; 66(5):363-377

    Objectives:

    1. List several chronic pelvic pain disorders for both men and women.
    2. List one relationship between pelvic pain and a psychiatric disorder.
    3. Describe at least two proposed mechanisms for the relationship between chronic pain disorders and somatoform disorders.

    Relevance:
    Chronic pelvic pain is common but poorly understood. Individuals with chronic pelvic pain may also experience psychiatric conditions that are important to identify, including somatoform disorders.

     
  12. WITHDRAWN
     
  13. Challenges to Integrate Mental Health Care into the New Primary Care Model in Brazil: A Low-Cost, Task-Shifted Management Program for Depressed Pregnant Women in Primary Health Care in Sao Paulo, Brazil
    Presenting Author:  Marcia Scazufca
    Co-Authors:  Alexandre Curi, Monica Mogadouro, Ariete Ramirez, Silvia Fenerich, Simone Almeida, Julieta Quayle, Luiz Dangelo, Renata Santos, Ricardo Araya, Paulo Menezes

    Introduction: Depression during pregnancy is frequent and can lead to negative outcomes. Much of mental health (MH) care in Brazil is now being integrated into the new primary health care (PHC) model, based on Family Health Teams (FHT). FHT are responsible for prenatal care of all women living on a defined geographic area. Barriers to the integration of MH care into PHC include lack of trained PHC professionals to deal with MH problems and scarcity of specialized MH professionals at secondary care level. In order to overcome these barriers we are testing a task-shifted, low-cost program (PROGRAVIDA) to treat depression during pregnancy in São Paulo.

    Objectives: To describe the study and the challenges faced in the process of implementing this program into PHC in São Paulo.

    Method: We are conducting a pragmatic randomized controlled trial to assess the efficacy of the PROGRAVIDA. All pregnant women attending the first prenatal consultation in 12 PHC Units with FHT were screened with the PHQ-2 and then assessed for depression (PHQ-9). Those with PHQ-9>4 were invited to participate in the PROGRAVIDA. Nurse assistants (NA) were responsible for delivering a 6-session psychosocial intervention based on problem solving methods at the home of participants. Outcomes are being assessed at 4 months after inclusion. Results will be compared with a usual care group.

    Results: Among the 3278 pregnant women screened (PHQ-2), 43% were positive on the PHQ-2 and 65% scored above a PHQ-9>4. 78% accepted to be included in the study. 40 NA were trained to deliver the intervention. Among the difficulties faced in the implementation of the program are: 1) NA were overloaded with other duties; 2) there was not enough support from managers and doctors in some of the clinics; 3) some pregnant women were reluctant to engage with the PROGRAVIDA – most of these women did not adhere to prenatal care. NA felt empowered with their new responsibilities and interest to receive further training on how to manage people with mental problems.

    Discussion: Task shifting is popular these days but there are a number of issues that need to be dealt with if we want to make sure this strategy can succeed in PHC. NA require a support system to undertake these new tasks, their additional needs to be recognized and rewarded, ongoing training and adequate supervision needs to be in place, and the whole team needs to accept the need for more efficient collaborative care. A program, such as PROGRAVIDA, that increases the identification and treatment of depression among pregnant women in PHC may be possible but these barriers need to be addressed comprehensively in order to achieve these goals.

    Objectives:

    1. Learn how the primary health care system in Brazil is organised and how it integrates with mental health.
    2. Understand the main barriers to care about pregnant women with depression in primary health care in low and middle-income countries.
    3. Recognize that low-cost interventions to deal with depression during pregnancy can be implemented in primary health care.

    Relevance:
    Depression is a public health problem and highly prevalent during pregnancy. However, the cost-effectiveness of low-cost interventions aimed at treating depression during this period are still scarce.

     
  14. [T] Factors Associated with Medication Adherence in Youth with Bipolar Disorder
    Presenting Author:  Loren Sobel
    Co-Authors:  Rachael Fersch-Podrat, Nina Hotkowski, Matthew Garcia, David Axelson, Boris Birmaher, Antoine Douaihy, Tina Goldstein

    Purpose: Poor medication adherence is high among adults with bipolar disorder and may be worse among youth with this diagnosis. The negative consequences of poor medication adherence include increased emergency resource utilization, rates of hospital readmissions and suicide attempts. The purpose of this study was to investigate factors that are associated with medication adherence in youth with bipolar disorder. We hypothesized that poor medication adherence in youth with bipolar disorder would be associated with patient age, side-effect burden, and family conflict.

    Method: Participants included 20 youth, ages 12-22 (mean age: 13.4 ± sd) who were diagnosed with BP I, II, or Not Otherwise Specified (NOS) using the K-SADS semi-structured interview. Participants were recruited from a pediatric clinic specializing in bipolar disorder. Youth were prescribed an average of 2.2 ± sd psychotropic medication to treat their mood and comorbid conditions. We assessed medication adherence via youth and parent report using a likert scale from 1-5 that estimated the percentage of time the youth missed a medication dose in the 2 weeks prior to study entry (1:less than 10% of the time to 5:greater than 80% of the time). For the analyses, we classified participants into medication adherent versus nonadherent groups. Medication adherence was defined as missing a medication dose less than 10% of the time. In cases of discordant ratings between parents and youth, the least adherent score was used to determine adherence classification. We evaluated the association between medication adherence and illness-specific (diagnosis type), patient (age, sex, socioeconomic status), treatment (side effect burden, medication regimen complexity), and developmental (concordance between parent and youth regarding medication adherence, family conflict) factors.

    Results: 15 (75%) participants were medication adherent compared to 5 (25%) who were nonadherent. There were no significant differences between medication adherent and nonadherent youth in illness-specific, patient, or treatment factors. Developmental factors were significantly associated with medication adherence. Youth and parent report of medication adherence was more concordant in the adherent group compared to the nonadherent group (90% concordance vs. 0% concordance; Χ2 = 11.25, p = 0.002). On the Conflict Behavior Questionnaire, the medication adherent group reported significantly lower levels of family conflict compared to the nonadherent group (3.2 ± 3.4 vs 9.6 ± 5.4; p = 0.006).

    Conclusion: Medication adherence was significantly associated with concordance between child- and parent-ratings of adherence, as well as less family conflict. These developmental factors may play a significant role in medication adherence. Given the serious negative consequences associated with poor medication adherence, treatment approaches for this population may aim to improve concordance and family conflict as a means of improving medication adherence in youth with bipolar disorder.

    Objectives:

    1. Discuss the importance of medication adherence in youth with bipolar disorder.
    2. Evaluate factors associated with medication adherence in youth with bipolar disorder.
    3. Consider the clinical implications for sex, concordance, and family conflict being associated with medication adherence in youth with bipolar disorder.

    Relevance:
    Medication adherence is essential in youth with bipolar disorder given the consequences of poor adherence. Identifying factors associated with adherence is critical for new treatments that aim to improve adherence.

     
  15. [T] Methamphetamine Abuse in Pregnant Women: A Review of Psychosocial Factors and Demographics
    Presenting Author:  Ian Steele
    Co-Authors:  Daniel Hosker, Nathaniel Barusch, Dylan Kathol, Jason Caplan

    Purpose: Methamphetamine (MA) abuse is epidemic in many areas of the United States, most likely due to the ease of manufacture, low cost, and the extreme high achieved. A particularly concerning finding is the rise of MA use by pregnant women. Multiple studies have examined the psychosocial attributes shared by pregnant women who abuse MA. Here, we review the available literature on the demographics and psychiatric comorbidities of pregnant women who abuse MA pregnancy.

    Method: A literature review was conducted, using PubMed, on articles published within the last 10 years. Key search terms were "methamphetamine", "pregnancy", and "demographics".

    Results: Approximately 5.8% of the population ages 12 and older have used MA at least once in their life, though this is likely an underestimation. The major areas affected by MA abuse are the midwest and (to a greater extent) the west (including Hawaii), accounting for almost 90% of MA users nationally. Young females experimenting with drugs have an increased risk of unprotected sex with multiple partners, thus leading to an increased risk of pregnancy. Currently, the most commonly identified primary drug of abuse for pregnant women in substance abuse treatment is MA. A longitudinal study examining the demographics of pregnant MA abusers revealed that those with younger age, unmarried status, Caucasian race, low socioeconomic status, poor educational background, history of psychiatric diagnoses, and legal involvement make up the majority of this group. It has also been noted that 30-45% of women who use MA during pregnancy also use alcohol, with concomitant use of both associated with an increased risk of having a primary psychiatric diagnosis. The more MA abuse that occurs during the course of pregnancy, the less these patients attend prenatal care visits (PCV). The opposite has shown to be true as well, with reduction in MA abuse associating with more PCVs attended, giving an optimistic outlook on the ability to achieve better outcomes on pregnant MA abusers if the problem can be identified and addressed in a timely fashion.

    Conclusions: There are many psychosocial factors commonly seen in pregnant women who abuse MA, such as low SES, psychiatric diagnoses, and being a single parent. Targeting women at risk for MA at the point of care may allow for timely diagnosis and treatment of MA abuse and associated factors, potentially increasing adherence to prenatal care.

    Objectives:

    1. Define the common psychosocial and demographic characteristics found in pregnant women at risk of methamphetamine abuse.
    2. Analyze the relationship between frequency of methamphetamine abuse and adherence to prenatal care.
    3. Examine the importance of early identification of methamphetamine abuse in pregnancy in order to optimize outcome.

    Relevance:
    Methamphetamine is the primary drug of abuse in many parts of the United States. Profiling pregnant patients at high risk for methamphetamine abuse may improve outcomes.

     
  16. [T] Neuropsychiatric Aspects of Anti-NMDA Receptor Encephalitis in Pediatric Patients
    Presenting Author:  Susan Turkel
    Co-Authors:  Sheryllence Ignacio, Matt Lallas, Jay Desai

    Introduction: A subset of acute encephalitis patients have seroreactivity against the NMDA-type glutamate receptor in neuronal post synaptic cell membranes. In adults, anti-NMDA receptor encephalitis is typically a paraneoplastic phenomenon. In children and adolescents, it is often not paraneoplastic but due to a para/peri/post infectious immune process. Pediatric anti-NMDA receptor encephalitis presents first with psychiatric symptoms, and neurologic symptoms soon follow. Clinical recovery may be protracted with outcome depending on early diagnoses and rapid immunomodulatory.

    Purpose: In order to characterize pediatric cases of anti-NMDA receptor encephalitis, we collaborated with colleagues in neurology to describe our two year experience at Children's Hospital Los Angeles.

    Methods: We retrospectively reviewed our cases of anti-NMDA receptor encephalitis at Children's Hospital Los Angeles from 2010 through 2012.

    Results: There were two girls and four boys seen in the past two years since immunologic diagnosis has been possible. They ranged in age from 5 to 14 years (mean 8 years). All presented with acute mental status changes, hallucinations, bizarre behavior, sleep disturbance, seizures, and abnormal movements. They received atypical antipsychotics and a variety of anticonvulsant medications. All were treated with high dose steroids and IVIG and three with rituximab. Clinical improvement has been slow, and cognitive impairment appears to persist after psychosis and dystonia resolve.

    Conclusions: Trainees in psychosomatic medicine need to consider anti-NMDA receptor encephalitis when patients present with acute psychosis and seizures. These patients provide insight into the role of NMDA function in neuropsychiatric disorders, emphasize the need for prompt recognition and intervention, and illustrate the importance of coordinated neurologic and psychiatric care.

    Objectives:

    1. To acquire an awareness of the neuropsychiatric presentation of anti-NMDA receptor encephalitis in children and adolescents.
    2. To become familiar with the current management of anti-NMDA receptor encephalitis in children and adolescents.
    3. To describe the likely outcome of anti-NMDA receptor encephalitis in children and adolescents.

    Relevance:
    Both pediatric psychiatrists and neurologists need to be able to recognize anti-NMDA receptor encephalitis and be able to collaborate to provide their shared patients the best available treatment and outcome.

     

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Section F:  Psycho-Oncology and Palliative Medicine

  1. [T] The Psychological Impact of Cervical Cancer Screening on Woman from Two Northern Indian Villages
    Presenting Author:  Kokil Chopra
    Co-Authors:  Shashi Prateek, Alexander Thompson, Surveen Ghumman, Kapil Chopra

    Purpose: To identify the effect of screening programs such as routine cervical cancer Papanicalou (PAP) smears on the psychological state and behaviour of participants. We accomplish this by examining participants' perceptions, attitudes, and experiences which may impede cancer screening participation. We also identify possible ways of improving women's acceptance of this screening.

    Methods: 450 women were screened routinely for cervical cancer or dysplasia by a PAP smear at rural health camps held in two villages of a Northern state of India. All patients were evaluated prior to administering the PAP smear for psychological stress based on a questionnaire adapted from the Psychosocial Effects of Abnormal Pap Smears Questionnaire (PEAPS Q Scale) that was translated to Hindi, the native language of the women visiting the health camp.

    Results: 180 (40%) women knew about cervical cancer as an existing illness while 115 (25.5%) women were aware of its signs and symptoms. 153 (34%) women said they felt tense before and about the procedure, 69 (15.3%) women thought they would feel vulnerable while the PAP smear will be taken, 32 (7.1%) felt their body might be invaded, and 90 (20%) thought that it would be an uncomfortable procedure. 160 (35.5%) women were worried that they might have cancer, 22 (4.8%) women feared death. 18 (4%) women were concerned that they might give cervical cancer to their sexual partner and 45 (10%) feared the loss of reproductive capacity. 125 (27.7%) women were worried that their relationship might change with people closest to them after completing cervical cancer screening.

    Conclusion: Women reported a wide range of negative experiences, perceptions and beliefs before getting a PAP smear. The types of negative perceptions and attitudes the participants demonstrated largely could be countered by improving their understanding of the process. We discuss ways to increasing that understanding for women in rural India.

    Objectives:

    1. Review what is known about the psychological impact cervical cancer screening has on women and how that impact may decrease appropriate cancer screening.
    2. Present a study assessing the psychological impact of routine cervical cancer screening on a large number of women from two villages in northern India.
    3. Discuss how understanding these psychological effects may allow us to better support woman accept and participate in cerivcal cancer screening.

    Relevance:
    Anxiety may limit womens’ participation in cervical cancer screening programs. It is important that we understand the psychological impact of such testing to better help women get appropriate cancern screening.

     
  2. Establishing End-of-Life Wishes of Patients with Guardians: Developing a Standard
    Presenting Author:  Elizabeth A. Davis
    Co-Author:  Rebecca Weintraub Brendel

    Purpose: Chronically mentally ill patients are rarely engaged in discussions regarding end-of-life wishes [1, 2]. When patients are adjudicated incompetent and appointed a guardian to make decisions about their medical care, their guardians are left in a position of making end-of-life decisions on their behalf [3]. Since chronically mentally ill patients have been shown to demonstrate variable decision-making capacity during the course of their psychiatric treatment [1], we will assess the ability of patients under guardianship to express their advanced directives for end-of-life care.

    Given the heavy burden of medical illness in this population, understanding patients' attitudes toward life-sustaining treatment and expectations regarding quality-of-life is warranted. There has been limited attention engaging this population in such discussions to determine how high the bar should be set regarding their competency to make these decisions [3].

    The medically enhanced psychiatric unit at Tewksbury Hospital is an ideal setting to explore patients' appreciation of end-of-life decisions and the consistency of their preferences. We will determine the threshold for finding patients competent so that their advance directives will be recognized as legally binding.

    Methods: An internist and social worker will conduct a structured interview using The Five Wishes [1, 4] as a framework to assess each patient's ability to generate advance directives regarding life-support measures. Patients will be asked to assign a surrogate decision maker who they believe will honor their wishes.

    Collateral data from family and court-appointed guardians will be factored in determining whether or not an individual's expressed wishes are consistent with their historical values and past attitudes toward healthcare.

    If the patient is able to express their wishes consistently and logically, a discussion with their preferred surrogate and/or guardian will be initiated so that the patient's advance directives are known. If there is a guardian, they will be able to collaborate in order to make a cohesive plan should the patient become catastrophically ill.

    Results: Each patient will have the opportunity to discuss their end-of-life wishes and choose a preferred surrogate decision maker. If indicated, the guardian will be included in a collaboration around the patient's advance directives. For those who cannot engage in the discussion meaningfully, the next-of-kin and guardian will be contacted to discuss a plan going forward so that the best interest of the patient can be accounted for when a non-recoverable event occurs.

    Conclusions: We expect to have a better understanding of the standard necessary to determine the end-of-life wishes of chronically mentally ill patients and whether or not the threshold should be lower for honoring advance directives than that for making medical decisions that would otherwise be deferred to the guardian. We believe that guardians will be more available to clinicians should they feel more supported in this process.

    Objectives:

    1. To understand competency issues when assigning a healthcare proxy among chronically mentally ill patients.
    2. To understand how to approach mentally ill patients, some of whom have a guardian, regarding their end-of-life wishes using a structured interview.
    3. To understand the role of the guardian when a patient has the ability to identify their advance directives.

    Relevance:
    Individuals with chronic mental illness, often the sickest among hospitalized patients, are rarely engaged in discussions regarding advance directives. Competancy issues are fundamental to the practice of psychosomatic medicine.

     
  3. A Pilot Study to Evaluate Symptom-Oriented Selection of Antidepressants in Patients with Cancer
    Presenting Author:  Eliza Park
    Co-Authors:  Ryan Raddin, Robert Hamer, Kelly Nelson, Deborah Mayer, Stephen Bernard, Donald Rosenstein

    Purpose: Major depressive disorder (MDD) is a common and debilitating illness in patients with cancer. However, the optimal treatment of depression in these patients remains uncertain, with limited evidence to support the use of psychopharmacologic therapy. Few randomized controlled trials have been performed in this population, and their results have been mixed. We conducted a pilot study to evaluate the feasibility of an antidepressant clinical trial in the oncology population and the process of symptom-oriented selection of antidepressants (citalopram or mirtazapine) in patients with cancer and MDD.

    Methods: This was a single center, two-arm, non-randomized, open-label, nine-week pilot study of mirtazapine or citalopram in patients with cancer and MDD. The primary endpoint was the feasibility to recruit and to retain patients. Secondary outcomes included changes in PHQ-9 (depression), FACT-G (quality of life), FACIT-Fatigue (fatigue), and PSQI (sleep) scores. We conducted descriptive statistics and responder analyses.

    Results: Eighteen of twenty-one patients (86%) successfully completed the study. An average of 2.8 subjects were enrolled per month. Mean scores on the PHQ-9 improved overall by 6.4 points (95% confidence interval [CI], 3.6 – 9.2). Additionally, mean FACT-G, FACIT-Fatigue, and PSQI scores improved in both study arms.

    Conclusions: Conducting antidepressant clinical trials is challenging in the oncology population. We approached, but did not meet our feasibility goals. Depression and quality of life scores improved with both mirtazapine and citalopram, but future, evidence-based, pharmacologic treatments for depression in cancer patients are needed. Experiences from this feasibility trial can inform supportive care research in oncology patients.

    Objectives:

    1. To review current strategies for pharmacologic treatment of depression in cancer patients.
    2. To discuss barriers to conducting psychiatric research in oncology populations.
    3. To develop strategies to improve supportive care research in cancer patients.

    Relevance:
    Depression commonly occurs in patients with cancer. Strategies to improve research for psychiatric disorders in oncology populations are needed.

     
  4. Assessing Quality in Psycho-Oncology
    Presenting Author:  Sarah Parsons
    Co-Authors:  Elizabeth Archer-Nanda, Isabel Schuermeyer, Marisa Crenshaw

    The treatment of cancer has experienced tremendous advancements over the past several decades; however, the treatment of associated psychological and emotional concerns have not consistently been integrated. The Commission on Cancer recommends psychosocial assessment as a standard of care. Among practices that have integrated mental health care as a standard of care, few have established evaluation and outcome metrics associated with screening and management of psychiatric sequelae after referral to specialized psychiatric services. A gap exists between clinical care and the integration of evidence-based treatment guidelines with as few as 27% of studies reviewed in the Institute of Medicine report showing adherence to treatment guidelines; the IOM recommends use of valid and reliable patient questionnaires to assess program and patient outcomes.

    The Norton Cancer Institute Behavioral Oncology Program in Louisville, Kentucky, is a fully embedded psychiatric program offering a spectrum of services to help medically complex patients and their families deal with cancer and related quality of life issues. A microsystem assessment of the Behavioral Oncology program was completed and found that 59% of patients seen by this service met DSM-IV criteria for a depressive spectrum diagnosis and were being managed for this psychiatric comorbidity. The Patient Health Questionnaire-9 item (PHQ-9) is a well-studied and reliable tool that has been validated in cancer patient populations. Quality improvement initiatives are at a very early stage in development and opportunities exist for benchmarking to assess clinical and functional outcomes. Further, use of standardized psychometrics will reduce treatment variability and ease the integration of evidence-based treatment guidelines within the department.

    Norton Cancer Institute Behavioral Oncology has launched a program-wide routine measurement of all patients at every visit with the PHQ-9. The Cleveland Clinic Foundation's Psycho-Oncology Program in Cleveland, OH has also been using PHQ-9 for sequential assessment of all patients seen by psychiatrists in their department.

    This paper will provide an illustration of integrated psychiatric programs' processes for evaluation of programmatic outcomes and integration of evidence-based guidelines. Preliminary data will be presented on sequential assessment with the PHQ-9, including demographic data, compliance with assessment, and disease specific observations.

    Objectives:

    1. Describe process improvement initiatives for integration of PHQ-9 assessment at regular intervals.
    2. Examine the Behavioral Oncology Program as a clinical microsystem for integration of evidence-based treatment guidelines.
    3. Illustrate preliminary outcome data based on sequential monitoring with PHQ-9 at two institutions.

    Relevance:
    Psycho-oncology is a vital part of cancer care and a common area of practice for psychosomatic physicians. Process improvement and quality outcome measures are important in today's healthcare climate.

     
  5. [T] “Why Do You Want to Stop Dialysis?”: Impact of Chronic Pain on Dialysis Withdrawal: A Case Report
    Presenting Author:  Piyapon Thisayakorn
    Co-Authors:  Paul Thisayakorn, Michelle Weckmann

    Purpose: The number of elderly patients with end-stage renal disease (ESRD) is growing and patient decisions to withhold/withdraw dialysis are becoming more common for a variety of reasons. It is important to explicitly explore reasons behind requests for discontinuation because the reason may be due to addressable symptoms. This case reviews such symptoms.

    Method: Individual chart review. The demographic data, clinical presentation, and management plan are described.

    Result: A 70-year old woman with depression, chronic pain, diabetes mellitus and ESRD receiving hemodialysis was admitted to medical ICU due to sepsis. After stabilization the patient required emergency hemodialysis for severe hyperkalemia.

    Unexpectedly, the patient refused to continue hemodialysis; however, her decision was inconsistent despite multiple family meetings and no clear reason for discontinuation was elicited. Unfortunately, she did not have any advance directives. Finally, psychiatry was consulted to evaluate for passive suicidal ideation, depression, and decisional capacity.

    On exam, her mood was sad. She admitted to having passive suicidal ideation and thought the only way to kill herself was to stop dialysis. She expressed fear of passing out and worsening pain after dialysis. The patient was explicitly asked about her reason for requesting hemodialysis termination, and she identified “pain” as the major factor. The patient had been suffered from worsening severe neuropathic pain in her legs over the past months. She stated that pain had significantly worsened her mood, broken her sleep, and compromised her quality of life. After an interdisciplinary discussion, the patient decided to resume hemodialysis as long as her pain was controlled.

    Throughout the remainder of her hospitalization, her pain was appropriately managed with analgesics and gabapentin, and depression was treated with citalopram. The patient noted significant improvement in her pain and depression. She was subsequently discharged and has continued on hemodialysis.

    Conclusion: This case demonstrates the importance of asking explicitly why a person is requesting to discontinue dialysis. Reasons for discontinuing dialysis are multiple and often revolve around quality of life. We know that the symptoms burden from dialysis can be similar to the symptom burden of end stage cancer. Retrospectively, despite the documentations of severe pain in this patient, symptoms were not addressed adequately and psychical and psychosocial burden were not explored. The dilemma in her case would have been solved with a simple question, “Why do you want to stop dialysis?” Effective communication skills are an important part of good care. Thus, simply asking clear and straight forward questions should not be overlooked, especially when caring for chronically ill and complex patients. Moreover, according to the RPA and ASN guidelines for withholding/withdrawing hemodialysis, advance care planning should always be discussed within patient and family.

    Objectives:

    1. This case demonstrates the importance of asking explicitly why a person is requesting to discontinue dialysis.
    2. Effective communication skills are an important part of good care.
    3. Guidelines for withholding/withdrawing hemodialysis, advance care planning should always be discussed within patient and family.

    Relevance:
    Multidisciplinary approach (psychiatry consultation, palliative care, internal medicine) in the complex end-of-life situation.

     
  6. [T] Palliative Care and Hospice Collaboration in Management of a Medical Psychiatry Patient
    Presenting Author:  Piyapon Thisayakorn
    Co-Authors:  Paul Thisayakorn, Michelle Weckmann

    Purpose: Dementia is a terminal disease and families need to be informed of this fact to make appropriate decisions regarding goals of care. When dementia progresses and symptoms are difficult to manage, hospice general inpatient (GIP) care is an alternative option which is often not considered. This case describes the use of inpatient hospice support to change the focus of care to intensive symptom management which can help ensure patient and family goals are met.

    Method: Individual chart review. The demographic data, clinical presentation, laboratory results, imaging study, and management are described.

    Result: A 65-year-old female with bipolar I disorder, dementia, hypertension, diabetes mellitus, and cervical disc herniation was admitted to a medical psychiatry unit for urinary tract infection, poor oral intake, pain, and altered mental status. During the hospital stay, her affect was extremely labile, and thought and speech were tangential and non-logical. She was disorientated, confused, agitated, disinhibited, and combative requiring restraints and seclusion for safety. Laboratory findings, MRI and EEG were unremarkable. Multiple medications trials (sodium valproate, quetiapine, risperidone, trazodone, haldol, olanzapine, lorazepam) were ineffective, as was 11 ECTs. After 3 months, the team decided that she had an irreversible dementia. Palliative care was consulted to assist with a family meeting to establish goals of care and code status.

    Psychiatry, internal medicine, palliative care and the patient’s children attended the family meeting. After the terminal nature of dementia was discussed, her famly clarified the goals as being close to family with a focus on comfort. However, the patient’s uncontrollable labile mood and aggression prevented placement at facilities closer to her family. To enhance comfort she was enrolled in hospice GIP care and the team agreed that it was reasonable to accept mild sedation if it decreased aggression and helped patient get back to the home community.

    With medicine, psychiatry, palliative care and hospice collaborative management, her pain was appropriately managed (fentanyl patches, prn morphine). Her behavior was better controlled with chlorpromazine and as prn lorazepam. Environmental adjustment with minimal stimulation, foot massage, and aromatherapy for relaxation were provided. Although the patient refused food and continued losing weight, no artificial alimentation was provided (congruent with goals).

    The patient’s behavior was dramatically improved although she was mildly sedated. Four weeks after GIP admission, she had a sudden condition change. Comfort measures continued and the patient died peacefully on the medical psychiatry unit.

    Conclusion: We describe a case of dementia with aggressive behavior which was successfully managed by collaboration between hospital and hospice staff via hospice GIP admission. This case emphasizes the importance of multidisciplinary approach and highlights the benefit of goals of care discussions.

    Objectives:

    1. We describe a case of dementia with aggressive behavior which was successfully managed by collaboration between hospital and hospice staff via hospice GIP admission.
    2. This case emphasizes the importance of multidisciplinary approach and highlights the benefit of goals of care discussions.
    3. Dementia is a terminal disease and families need to be informed of this fact to make appropriate decision regarding goals of care.

    Relevance:
    This case describes the use of inpatient hospice support for terminal stage of dementia of psychiatric symptoms.

     

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Section G:  Psychopharmacology and Substance Abuse

  1. [T] False Positive Results on Urine Drug Screening: A Review
    Presenting Author:  Nathaniel Barusch
    Co-Authors:  Dylan Kathol, Ian Steele, Daniel Hosker, Jason Caplan

    Background: Use of the ELISA drug test is increasingly prevalent in a variety of settings including employment screening, pain management contract enforcement, and welfare eligibility screening. While manufacturers of these tests claim better than 99% accuracy, there is an increasing body of reports demonstrating false positives in response to certain medications, with potentially dire consequences for those tested. Some of these interactions can be expected (for example, prescribed opioids can prompt positive heroin screens), but others are more obscure (for instance, the quinine found in tonic water can cause a false positive for opiates). We aim to provide a comprehensive list of substances shown to cause a false positive on ELISA drug tests. These data show the need for more specific methods of drug screening, as well as clinical judgment in interpreting the results of current screening methods.

    Methods: A literature review was conducted using the search terms "false positive" + "drug screen" as well as "drug test" and "ELISA drug test" in the PubMed search engine. To ensure results were comprehensive, the same methods were carried out on a Google Scholar search with the first 3 pages examined, and included if they were from peer-reviewed journals.

    Results: Our literature review has found 74 substances that can cause a false positive for THC, 189 for amphetamines, 52 for morphine, 67 for MDMA, 152 for opiates, 42 for barbiturates, 88 for benzodiazepines, 22 for TCAs, 10 for Cocaine, 34 for LSD, 11 for Methadone, 14 for PCP, and 19 for codeine.

    Conclusion: This review demonstrates the fallibility of the ELISA drug screen. It appears to be vulnerable to false positives from a wide range of substances. More specific drug screening tests are needed, and until they are developed, positive drug tests must be interpreted with a certain degree of skepticism. Undoubtedly the majority of positive ELISA results are true positives, but when the consequences of a false positive are dire, clinicians must be aware of the risk of false positives from the substances shown.

    Objectives:

    1. Explain the mechanism of the urine drug screening and why it may be prone to false positive results.
    2. Analyze the potential ramifications of false positive toxicology results across an array of clinical scenarios.
    3. Investigate alternative protocols for clinical decision making when drug screening is an important variable.

    Relevance:
    Urine drug screening is used in a variety of clinical settings but results of the test may be unreliable. It is important that clinicians are aware of potential cross-reactive substances.

     
  2. [T] Aseptic Meningitis Following Illicit Substance Ingestion
    Presenting Author:  Rebecca Bauer
    Co-Author:  Christina Wichman

    Background: Illicit substances affect the central nervous system in numerous ways, often manipulating neurochemical pathways to produce their addictive potential. However, illicit substances have yet to be associated with causing meningitis. Drug-induced aseptic meningitis (DIAM) is a rare reaction to numerous commonly used drugs and is often a diagnosis of exclusion.

    Method: This is the first report of a potential illicit substance-induced meningitis.

    Results: A young male experienced onset of aseptic meningitis with pronounced psychotic symptoms following reported ingestion of illicit substances on the day prior to admission. Following cessation of any illicit substance ingestion, the patient improved within four days.

    Discussion: This case suggets a potentially novel reaction to illicit substances, a reaction psychiatrists, especially consultation psychiatrists, should explore in patients with an extensive drug abuse history and an onset of meningitis of unknown etiology.

    Objectives:

    1. Investigate and consider the potential for illicit substances to induce meningitis, similar to many drugs, especially in patients with extensive substance abuse histories.
    2. Prioritize steps in a work-up when consulted on a patient with aseptic meningitis of unknown etiology, including a thorough substance abuse history and appreciate various confounders that can occur.
    3. Appreciate the potential for illicit substances to induce meningitis and apply this knowledge to future consultations, therefore encouraging substance rehabilitation and cessation to prevent a future reaction.

    Relevance:
    The presentation is relevant in that it suggests a potential association between illicit substances and aseptic meningitis, something that has not yet been described in the literature.

     
  3. The Many Safe and Effective Uses of Clonidine and the Clonidine Patch: From Opiate Withdrawal to PTSD and Agitation
    Presenting Author:  Bradford Bobrin

    We have been treating many patients with histories of opiate depence, PTSD, anxiety disorders, opiate dependence and anxiety, opiate withdrawal and agitation, especially associated with histories of head injury and probable chronic traumatic encephalopathy with histories of ineffective treatment with other medications and repeated hospitalizations. With want for another medication, we scoured the literature to find that clonidine has been looked at, at least in brief studies, to treat a panopoly of conditions. With this information, we embarked to use clonidine, especially the patch, for a number of conditions. We would like to summarize our experience with several case reviewes of our successful treatment with clonidine for the following conditions:

    Opiate detoxification: We will report several cases of successful opiate detoxification with the clonidine patch with doses betwen 0.1-0.2 without vital sign alteration and in cases where the patients reported anxiety as a reason for opiate use, the successful treatment of anxiety with reduction or elimination of cravings by the continued use of the patch at the detox dose through the hospitalization into discharge. We will also report several patients who had to remove the patch due to finances who had return of anxiety symptoms.

    PTSD: We will report several cases of patients with sevre PTSD with active anxitey, re-experiencing, sleeplessness and nightmares who responded with either sleep where they previously had none to the need for the patch for sleep, reduction of nightmares and flashbacks. Again, there were no vital sign alterations or symptoms of hypotension.

    Agitation: We report several cases of patients with explosive disorder, head injuries and mood disorder who presented with agitaton and homicidal ideation who responded with decreasing agitation and a decrease in homicidal ideation with the use of the clonidine, mostly 0.2mg patch without hypotension.

    In all these cases, blood pressure was measured initially and if greater than 100/60, clonidine was started, VS was monitored every four hours in the beginning of treatment until such time as a steady pattern of VS emerged and VS decreased in frequency to standard protocol. EKG was obtained in patients with a history of heart disease or arrythmia. Clonidine was held in cases of bp<90/60 or hr<60. There was one case in which the patient kept a HR between 59-55 in which the clonidine was continued due to lack of symptoms.

    Objectives:

    1. Become familiar with the use of clonidine for patients in opiate withdrawal.
    2. Become familiar with the use of clonidine for PTSD and other anxiey conditions.
    3. Become familiar with the use of clonidine for patients with anger/impulsive/explosive disorders.

    Relevance:
    Frequently we treat patients with anxiety, PTSD and withdrawal who have had poor response to other medications. Evidence of efficacy and safety helps practioners expand their therapeautic armamentarium

     
  4. Two-Day, 16mg Suboxone Opiate Detoxification Regimen
    Presenting Author:  Bradford Bobrin

    We present several successful cases of opiate detoxification using a two day regimen of once-daily dosing of 16mg of suboxone. In these cases opiate-dependent patients were admitted and placed on our usual opiate detox protocol of the clonidine patch 0.1 with q 4h vitals, hold paramneters of <90/60 or HR<60, cyclobenzaprine 10mg q8h prn, compazine 10mg q4h prn, ibuprofen 600mg q6h prn and loperamide 2mg q8h prn. After 24 hours, the patients continued to complain of severe withdrawal symptoms and previous lack of success with clonidine. Not wanting to place these patients on protracted taper nor being able to establish outpatient suboxone and being aware of a literature on high dose single dose suboxone, these patients were given a one-time dose of 16mg of suboxone. These patients has marked reduction of symptoms without any signs of sedation, ataxia or VS alterations. In addition, their clonidine pataches were continued without negative effect. The next day the patients continued to complain of symptoms despite the previous meds, so a second dose of 16mg suboxone was given. This allowed for complete resolution of symptoms without any further suboxne dosing. In addition, their clonidine patches were continued without any negtive effects and the continuation of the clonidine frequently alleviated associated anxiety and reduced the desire for opiates after the suboxne was no longer continued. We will present a summary of the literature on this subject with the poster.

    Objectives:

    1. Learn an alternative suboxone detox method different from that usually described.
    2. Learn that high dose single or split high dose suboxone is both effective and safe.
    3. Become familiar with the usual opiate detox methods in existence.

    Relevance:
    Since opiate withdrawal can be so disruptive to treatment, a rapid detox would be advantageous in gettiing the patient to a therapeautic place more quickly. This technique allows for this.

     
  5. [T] HLA Genotyping in Carbamazepine-Induced Cutaneous Reactions
    Presenting Author:  Jason Caplan
    Co-Authors:  Ryan Trowbridge, Benjamin Lockshin, Jason Caplan

    Purpose: Carbamazepine, a commonly used mood stabilizer, is the most common drug associated with Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). These two conditions are life-threatening and require emergent management. Recently, an association has been established between carbamazepine-induced SJS/TEN and certain HLA genotypes which may allow for future screening and prevention of carbamazepine-induced cutaneous reactions. This paper reviews the available literature on HLA genotypes associated with such adverse reactions, which populations are most at risk, and the cost effectiveness of screening.

    Method: A literature review was conducted using PubMed of articles published within the last 10 years. Key search terms used were "carbamazepine"," HLA", and "cutaneous".

    Results: Immunologic mechanisms play a significant role in carbamazepine-induced adverse cutaneous reactions and these reactions occur at a higher rate in Asian populations. HLA-B 1502 in Chinese patients and HLA-A 3101 in Japanese patients have been noted to be associated with increased risk of carbamazepine hypersensitivity. The FDA has recently recommended genetic testing before starting carbamazepine and added a warning to the product label against using the drug in Asians or those known to have HLA-B 1502. Patients carrying the HLA-B 1502 allele are 100 times more susceptible to carbamazepine-induced SJS/TEN and patients carrying the HLA-A 3101 allele are 9 times more susceptible to such reactions. A meta-analysis pooling 23 studies reported a number needed to screen of 461 for the HLA-B 1502 subtype to prevent one carbamazepine-induced drug hypersensitivity reaction. The number needed to screen for HLA-B 3101 was only 47. HLA frequency varies between Asian subpopulations; the prevalence of HLA-B 1502 is highest in Malaysia, India and Thailand. One study concluded that it is cost-effective to screen for HLA-B 1502 in Singaporian Chinese and Malays, but not Singaporian Indians since the population allele frequencies of HLA-B 1502 vary between ethnicities.

    Conclusions: Certain HLA subtypes are strongly associated with carbamazepine-induced SJS/TEN. These genes are most common in Asian populations, but vary broadly over different subpopulations within this group. Psychiatrists should be aware of the risk of these life-threatening conditions when prescribing carbamazepine and consider HLA genotyping, especially when prescribing for patients of Asian ethnicity.

    Objectives:

    1. Recognize which HLA genotypes are associated with carbamazepine-induced adverse cutaneous reactions.
    2. Compare the prevalence of HLA genotypes in various populations and assess the resulting risk of carbamazepine-induced cutaneous adverse reactions.
    3. Assess cost-effectiveness of screening for HLA-B 1502 in Asian subpopulations.

    Relevance:
    Certain HLA subtypes are associated with carbamazepine-induced SJS/TEN. Psychiatrists should be aware of potential for these life-threatening conditions when prescribing carbamazepine and consider HLA genotyping to clarify the risk.

     
  6. Attitudes Towards Antidepressant and Antianxiety Medications in Inpatients on General Medical Units
    Presenting Author:  Paul Desan
    Co-Authors:  Sara Gostoli, Andrea Weinstein

    Purpose: To examine attitudes towards antidepressant and antianxiety medications in patients hospitalized on general medical units.

    Methods: Patients (n=207) on general medical units at Yale New Haven Hospital were contacted and asked to complete a questionnaire. The questionnaire contained basic demographic questions; 20 items regarding antidepressant medications to be marked on a 5-point Likert scale from strongly agree to strongly disagree; a similar set of items regarding antianxiety medications; the Hospital Anxiety Depression Scale; and items regarding past and current use of antidepressants, familiarity with others taking such medications, and current mood and anxiety state. Subjects were excluded if they refused consent, appeared confused or impaired in mental state, or were not adequately fluent in English.

    Results: Over 70% of subjects had favorable views of antidepressants in general: would be supportive if a relative or friend was taking an antidepressant, agreed that antidepressants had helped many people, agreed that antidepressants were widely accepted, but had mixed views regarding whether they themselves would take an antidepressant. Over 70% of subjects felt that antidepressants make people feel doped up or dulled, are addictive, can make people suicidal, only cover up problems, and have more than mild side effects. Being unmarried, being unemployed, having less than a high school education and having an age >55 were associated with small but statistically significant decreases in total % favorable views of antidepressant medications. 62% of subjects indicated that they would take an antidepressant if recommended by their physician, 18% would be willing to take an antidepressant but for not more than 3 months, and 20% would not be willing. Subjects willing to take an antidepressant for a limited period were distinguished by stronger concerns regarding the addictive and dependency properties of antidepressants and feeling that people should be able to handle their own problems (all statistically significant at p<0.001). The responses to items concerning antianxiety medications were highly similar to those concerning antidepressant medications: there was a small but statistically significant difference in % agreement for 3 of 20 items.

    Conclusions: Most subjects disagree with strongly prejudicial views about antidepressant medications, but a majority feel that antidepressant medications are sedating, associated with high side effects, predispose to suicide and addictive. There is little understanding of the difference between antidepressant and antianxiety medications. About one quarter of patients willing to take antidepressants believe they should take such medications for less than 3 months. Given these opinions, poor rates of compliance with the initiation and continuation of antidepressant therapy are not surprising.

    Objectives:

    1. To understand attitudes about antidepressant and antianxiety medications in medically hospitalized patients.
    2. To understand how such attitudes are influenced by demographic and clinical factors.
    3. To understand how compliance may be affected by attitudes, and thus how physicians may seek to improve patient acceptance.

    Relevance:
    Consult psychiatrists will learn skills to improve compliance with medications for mood and anxiety disorders.

     
  7. [T] Olanzapine-Induced Sialorrhea
    Presenting Author:  Rajasekhar Kannali
    Co-Authors:  Waqar Rizvi, Howard Gottesman, Mallika Lavakumar

    Background: Hypersalivation due to antipsychotics is well known since the introduction of the first typical antipsychotics and with atypical antipsychotics mechanistically similar to the typical ones. The most widely accepted explanation for hypersalivation that occurs during use of antipsychotics is dopamine receptor blockade resulting in extrapyramidal side effects (EPS). Hypersalivation has also been observed in patients taking clozapine and its close relative, olanzapine, via a different mechanism of action. Our goal is to alert physicians to this rare but treatment-interfering side effect, to discus proposed mechanisms of action, and to explore management options.

    Method: Case Report

    Results: We report the case of a 21 year old man with no previous psychiatric history who was brought in for a manic episode with psychotic features and admitted for further evaluation and treatment. He was treated with olanzapine 10 mg BID, lorazepam 1 mg TID, and valproate 750 mg TID. Within a few days, he began to have signs of diplopia, staggering gait, and slurred speech concurrent with a supratherapeutic valproate level. He was also noted to have increased lethargy and sialorrhea, which was presumed to be due to lorazepam. The valproate and the lorazepam were discontinued. There was minimal improvement in mania. The above mentioned side effects improved, with the exception of sialorhea. Benztropine was added given the concern that sialorrhea was due to EPS, albeit, without any relief. Olanzapine was discontinued and was replaced with quetiapine resulting in resolution of sialorrhea. While on olanzapine the patient had normal gait and muscular rigidity, and contractions were absent. This suggested that the hypersalivation did not represent EPS and was not due to dopamine antagonism. Valproate and lorazepam were reintroduced and stabilized the patient.

    Conclusion: There have been a few case reports of hypersalivation associated with olanzapine. This report adds to this collection and supports this observation. Physicians caring for patients should be aware of olanzapine-induced sialorrhea. Proposed mechanisms of action include agonism of the M4 receptor and alpha-1 antagonism. For this reason anticholinergics, such as benztropine that reverse hypersalivation when it occurs due to EPS, fail to control this side effect. Non-pharmacological strategies include sleeping with a pillow propped up or placing a towel under the pillow. Tried and tested pharmacological strategies for controlling olanzapine induced sialorrhea are lacking. Although the agents responsible for antipsychotic induced sialorrhea may be effective in treating the psychosis or mania of a patient, switching to another antipsychotic is a potential solution for the hypersalivation itself.

    References:

    1. Perkins DO, McClure RK: Hypersalivation coincident with olanzapine treatment. Am J Psychiatry 1998; 155(7):993-4.

    2. Safferman A, Lieberman JA, Kane JM, Szymanski S, Kinon B: Update on the clinical efficacy and side effects of clozapine. Schizophr Bull 1991; 177:247-261.

    Objectives:

    1. To better establish the relationship between the rare side effect of sialorrhea and olanzapine.
    2. To understand the different mechanism of actions which can cause the side effect.
    3. To be aware of the different treatment options in the event of a hypersalivatory side effect.

    Relevance:
    Sialorrhea is a rare side effect of clozapine and olanzapine, which can be treated, if the cause of the side effect is better understood.

     
  8. [T] Paradoxical Side Effects of Olanzapine
    Presenting Author:  Anbreen Khizar
    Co-Authors:  Humaira Shoaib, Rashi Aggarwal

    Background: Atypical antipsychotic medications are the main stay for treatment of psychosis. Usual side effects are variable depending on the specific antipsychotic medication. Paroxysmal perceptual alterations (PPA) have been reported as uncommon side effects of antipsychotics. PPA is characterized by hypersensitivity of perception mainly in visual modalities. PPA could occur in patients treated with antipsychotics, typicals and atypicals .

    We report a case of an elderly Caucasian male who developed tactile and visual hallucinations after he was started on olanzapine. To our knowledge, only one case has been reported in which olanzapine was a possible cause of hypnopompic hallucinations.

    Case Report: We present a case of a 71 yr old Caucasian male with a long standing history of schizophrenia and parkinsonism secondary to antipsychotics, on thiothixene, trihexyphenidyl, lithium and amantadine. He was initially admitted to medicine for neuroleptic malignant syndrome. Thiothixene and lithium were discontinued. Once stabilized, patient was transferred to psychiatry service and started on quetiapine 25 mg po daily which was stopped due to increasing agitation and confusion thought to be secondary to delirium.

    Patient at that time was not exhibiting psychotic symptoms although he was having difficulty sleeping and had a poor appetite. Patient was on amantadine and trihexyphenidyl. Olanzapine 5 mg po daily was started. On the second day of starting olanzapine, patient started having tactile and visual hallucinations and was found picking at bed sheet, his clothes and skin stating that the hospital doesn’t do anything about the bugs crawling all over his body. As the patient at this time was alert, oriented to time, place and person and did not show any fluctuations in his symptoms, delirium was ruled out. Olanzapine was discontinued the same day after which patient stopped having hallucinations.

    Discussion: There is very scarce to no literary evidence regarding antipsychotics induced hallucinations. Alternatively, paroxysmal perceptual alterations are brief episodes of perceptual alterations mostly in the visual modalities and patients may see light much brighter, objects may appear closer and bigger, and tiny things such as dust and paper appear more emphasized. These episodes last for some time before they disappear.

    Administration of amantadine and olanzapine together could be responsible for the new hallucinations although we are not sure of the mechanism. Through our case presentation we suggest that exploring more about antipsychotics, their uncommon side effects and interactions will affect the treatment, prognosis and outcomes of psychosis tremendously, especially in older patients. Through more case reviews and studies, we hope to explore more and to contribute further to this narrow and limited area of research.

    Objectives:

    1. To provide a perspective on possible unusual side effects of atypical antipsychotics.
    2. To be able to understand the complexity of treatment of schizophrenia in the elderly.
    3. To understand the interaction pattern of medications in an elderly patient with schizophrenia.

    Relevance:
    Atypical antipsychotics particularly olanzapine is very widely used among patients with schizophrenia. Audience is going to learn about some rare side effects that resulted from olanzapine use.

     
  9. [T] CYP2C19 Variation, Citalopram Dose and QTc Prolongation on Electrocardiogram
    Presenting Author:  Yingying Kumar
    Co-Authors:  Simon Kung, David Mrazek, Gen Shinozaki

    Purpose: Recent FDA Drug Safety Communications in August 2011 and March 2012 to the citalopram drug label include warnings on a potential dose-dependent risk of QTc prolongation and Torsades de Pointes. Several studies show that the plasma concentration of citalopram is affected by CYP2C19 variants. Poor metabolizers of CYP2C19 had a reduced clearance of citalopram. Patients with decreased metabolism tend to be less tolerant of the medication. Here we examine whether CYP2C19 variation affects the risk of QTc interval prolongation for patients taking citalopram.

    Methods: Retrospective chart review of 748 consecutive patients with genotyping obtained between August 2004 to October 2008 at Mayo Clinic, Rochester, Minnesota, identified 75 patients with electrocardiograms (ECG) at time of citalopram use. CYP2C19 genotypes were categorized into extensive metabolizers (EM), intermediate metabolizers (IM), and poor metabolizers (PM) based on established guidelines. For analysis, IM and PM groups were combined due to limited number of PM. Automated heart rate and QT corrected (QTc) intervals from ECG and citalopram dose were obtained from electronic medical records. One way ANOVA was used to examine the relationship between CYP2C19 variation and QTc interval. Regression analysis was used to examine the relationship between citalopram dose and QTc interval.

    Results: Of 75 patients with citalopram (75% female, mean age = 43.55 SD 12.1), CYP2C19 distribution were 58 EM, 16 IM, and 1 PM. Patients who were CYP2C19 IM+PM tended to have a longer QTc than EM patients (440.1ms versus 427.1ms, respectively , p=0.029). When the CYP2C19 PM patient is excluded from analysis, this statistically significance disappears. However, there still exists a trend for CYP2C19 IM patients to have a longer QTc than EM (437.4ms versus 427.1ms, respectively, p = 0.066) Contrary to FDA Drug Safety Communication, there was no statistical significant effect of citalopram dose on QTc prolongation (adjusted R2=0.001, p=0.3). There was no statistical significant association between CYP2C19 variation and age, race, citalopram dose, or heart rate. QTc was also found to be significantly associated with age (p=0.0215), but not with gender or ethnicity.

    Conclusions: This study shows variation in CYP2C19 to have some influence on QTc interval prolongation in patients taking citalopram. However, this seems to be independent of citalopram dose as there was no association between medication dose and either QTc or CYP2C19 phenotype.

    References:

    1. FDA Drug Safety Communication: Revised recommendations for Celexa (citalopram hydrobromide) related to a potential risk of abnormal heart rhythms with high doses. http://www.fda.gov/Drugs/DrugSafety/ucm297391.htm

    2. Mrazek DA, Biernacka JM, O'Kane DJ, Black JL, Cunningham JM, Drews MS, et al: CYP2C19 variation and citalopram response. Pharmacogenet Genomics 2011; 21(1):1-9.

    Objectives:

    1. Appreciate the controversy surrounding use of citalopram at levels greater than 40 and risk for QT prolongation.
    2. Appreciate the role of genetic variation in citalopram metabolism and influence on medication tolerance.
    3. Consider genetic variation and pharmacokinetics in patients on citalopram as a risk factor for QTc prolongation.

    Relevance:
    Clinicans using citalopram should be aware of genetic variations that can affect medication metabolism and influence drug tolerance, such as QT prolongation.

     
  10. [T] Short-term Mortality and Morbidity after Surgery for Patients Prescribed Anxiolytic and Antidepressant Medication
    Presenting Author:  Clark Lester
    Co-Authors:  Karen Lommel, Lori Mutiso, Daniel Davenport

    Purpose: Serious mental illness has been reported as high as 5% in general population, of which 52.6% receive prescription medication. There has been significant attention on antidepressants in the literature, but anxiolytics have been understudied, particularly in relation to other acute health care processes. This study aims to determine the relationship between anxiolytic medications and complications after surgery.

    Methods: This study was a retrospective review of surgical patient data obtained at a major university medical center as part of the American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP). The ACS NSQIP is a prospective, 100% sample of 20 major surgical procedures performed at our hospital between October 1, 2011 and September 30, 2012. The data includes demographics, >30 comorbid clinical risks, procedural variables and 21 complications and death for up to 30 days after major surgery. Major morbidity (MM) was defined as a patient having one or more of the complications or death. Anxiolytic prescription medication (AXM) was identified at admission.

    Results: We reviewed a total of 1847 surgical patients with 289 (15.6%) AXM. AXM rates varied significantly by type of procedure (p <.001) with arto-iliac bypass and breast reconstruction patients having >25% AXM while appendectomy and prostatectomy <7% AXM. Operative duration was ½ hour longer on average in AXM patients (p<.001) who were also more likely to be smokers, suffer from COPD, dyspnea and hypertension (all p <.001). They had higher MM (24.3% AXM vs 14.9% without, p <.001), particularly infections (16.3% vs. 9.4%, p = .001), 1 day longer median hospital stay (3 vs 2 days, p <.001). In multivariable regression analysis, AXM was an independent predictor of MM (odds ratio 1.73, 95% CI 1.09-2.75, p=.021) after adjustment for thirteen procedural, clinical and demographic risk factors.

    Conclusions: We found significant differences in several surgical outcomes for those prescribed anxiolytics. Future studies are needed to evaluate surgical outcomes of patients receiving pharmacological treatment for anxiety.

    Objectives:

    1. Have a better understanding of how anxiolytic medications can affect surgical outcomes across a variety of surgeries.
    2. Have a better understanding of the comorbidities of the patients who are receiving anxiolytics.
    3. Be able to apply this knowledge directly in how to treat patients for anxiety undergoing surgical procedures.

    Relevance:
    Currently, the relationship of anxiolytics to other health-care processes has been understudied. This study provides evidence that anxiolytic medication is an independent predictor of major morbidity after surgery.

     
  11. Pain and the City: Observational Evidence that Urbanization and Neighborhood Deprivation Are Associated with Escalation in Chronic Analgesic Treatment
    Presenting Author:  Carsten Leue

    Objective: To examine, in the light of the association between urban environment and poor mental health, whether urbanization and neighborhood deprivation are associated with analgesic escalation in chronic pharmacological pain treatment, and whether escalation is associated with prescriptions of psychotropic medication.

    Method: Longitudinal analysis of a population-based routine dispensing database in the Netherlands, covering 73% of the Dutch nationwide medication consumption in the primary care and hospital outpatient settings over a six-month observation period, by ordered logistic multivariate model evaluating analgesic treatment.

    Main Outcome Measure: Escalation of analgesics (i.e., change to a higher level of analgesic potency, classified across five levels) in association with urbanization (five levels) and dichotomous neighborhood deprivation.

    Results: 449 410 patients aged 15-85 years were included, of whom 166 374 were in the Starter group and 283 036 in the Continuation group of chronic analgesic treatment. In both Starter and Continuation groups, escalation was positively associated with urbanization in a dose-response fashion (Starter group: OR (urbanization level 1 compared to level 5): 1.24; 95% CI 1.18 to 1.30; Continuation group: OR 1.18; 95% CI 1.14 to 1.23). An additional association was apparent with neighborhood deprivation (Starter group: OR 1.07; 95% CI 1.02 to 1.11; Continuation group: OR 1.04; 95% CI 1.01 to 1.08). Use of somatic and particularly psychotropic co-medication was associated with escalation in both groups.

    Conclusion: Escalation of chronic analgesic treatment is associated with urban and deprived environments, and occurs in a context of adding psychotropic medication prescriptions. These findings suggest that pain outcomes and mental health outcomes share factors that increase risk and remedy suffering.

    Objectives:

    1. Be able to recognize and realize escalation of analgesics.
    2. Be able to investigate associations of pain prescriptions with mental health issues.
    3. Be able to apply integrated care strategies in persistent pain conditions.

    Relevance:
    Persistent pain can be caused by social experinces. Due to that opiate prescription has become a major problem, not only in the US.

     
  12. [T] Somatic Symptoms as Indicators of Potential Endophenotypes in Bipolar Spectrum Disorders: An Explorative and Proof of Concept Study Comparing Bipolar II Disorder with Recurrent Brief Depression and Healthy Controls
    Presenting Author:  Hans Lövdahl
    Co-Authors:  Erlend Bøen, Eva A. Malt, Ulrik Fr. Malt

    Background: We examined if somatic symptoms associated with bipolar 2 disorders (BD-2) and recurrent brief depression with (RBD-H) or without (RBD-O) history of hypomanic symptoms might point to possible underlying disease markers (endophenotypes). We hypothesized that somatic symptoms being possible indirect indicators of endophenotypes should a) be more prevalent among patients than healthy controls; b) not be correlated to neuroticism; c) not be correlated to the severity of current mental status (e.g. anxiety, depression) and d) not be correlated with the use of psychotropic drugs.

    Methods: Sixty-one patients, 21 with BD-2; 19 with RBD-H and 21 with RBD-O were compared with 21 healthy controls. Assessments included a 123-item somatic symptom checklist; neuroticism (EPQ-N) and anxiety and depression (HAD, MADRS). Candidate somatic symptoms were selected through a stepwise inclusion/exclusion procedure (a-d).

    Results: Difficulties finding words when speaking; impaired hearing; impaired smell, and items suggesting autonomic dysfunction in addition to symptoms known to be associated with bipolar spectrum disorders (e.g. pain, fatigue), but also some symptoms already suggested to be endophenotypes (e.g., memory problems, migraine) survived the steps a-d.

    Conclusion: Our approach identified some symptoms that have been suggested to be associated with bipolar spectrum disorders, but also symptoms not commonly associated with bipolar disorders. The findings support the feasibility and validity of using assessment of somatic symptoms as a supplementary approach to identify potential endophenotypes in bipolar spectrum disorders.

    Objectives:

    1. Identify somatic symptoms of bipolar spectrum disorders which may falsely be attributed to a somatoform or bodily distress disorder.
    2. Distinguish episode-related somatic symptoms from symptoms pointing to endophenotypes.
    3. Know which additional somatic examinations and tests are needed to verify the diagnosis and choose appropriate treatment.

    Relevance:
    This paper deals with clinical presentations seen by most C-L psychiatrists, but nevertheless rarely addressed in Academy meetings.

     
  13. [T] Associations Between HIV Progression and Substance Use, Alcohol Use, and History of Trauma
    Presenting Author:  Constanza Martinez-Pinanez
    Co-Authors:  Ramaswamy Viswanathan, Kashmira Rustomji, Jameela Yusuff, Sophia Gibbs-Cohen, Stephen Goldfinger

    Background: CD4 count can be used as a proxy measure to evaluate health status, progression of the illness, and adherence to treatment in patients living with HIV/AIDS. Psychosocial and behavioral factors can affect adherence to antiretroviral medications and progression of the illness.

    Methods: This is a retrospective chart review study of patients new to the STAR (HIV) Clinic at UHB during the period between 7-1-07 and 6-30-08 (n=167) . IRB approval was obtained prior to study inception. Data pertinent to social history, substance use and demographics obtained at the beginning of their enrollment, and CD4 count during a 2-year period after enrollment, were analyzed. The independent variables included were history of emotional or sexual/physical trauma, alcohol use, problematic alcohol use, and substance use. The dependent variable was the difference between the last CD4 count and the first CD4 count. We divided our sample into individuals whose CD4 counts increased between the first and last counts and those whose CD4 counts decreased (improving versus worsening CD4 counts). We tested relationships between CD4 count progression and substance use, problematic alcohol use and history of trauma, using chi-square test, setting a significance level of 0.05, and calculated odds ratios (OR).

    Results: History of substance use was significantly associated with worsening of the CD4 count during the period of the study (OR 3.4, χ2 9.5, df 1, p< 0.002).

    Conclusion: This study suggests that a history of substance use is related to worse course in HIV patients as measured by CD4 counts. Further research needs to be done to explore if there is a causal relationship, and if so, if it is due to non-adherence to treatment and/or direct biological effects of substance use.

    Objectives:

    1. Analyze impact of psychological factors and substance use in HIV disease progression.
    2. Recognize the role of trauma in patients living with HIV/AIDS.
    3. Apply learned concepts in clinical practice to improve patient care, medication adherence, and retention in care.

    Relevance:
    Amongst known factors, substance use is a known predictor of HIV medication non-adherence.

     
  14. [T] Substance-Induced Panic Attacks and Hypomania from Selegiline and Phenylethylamine
    Presenting Author:  Alastair McKean
    Co-Authors:  Folabo Dare, Christopher Sola, Kathryn Schak

    Purpose: Increasingly, patients have access to Internet pharmacies that provide unrestricted access to psychotropic medications. The ability to obtain these medications with minimal to no physician oversight in combination with an increasing number of over-the-counter (OTC) substances that produce "legal highs" can place patients at high risk for morbidity and mortality. We describe a case of substance-induced hypomania precipitated by the selective irreversible monoamine oxidase B inhibitor (MAOI), selegiline, used in combination with the stimulant, phenylethylamine (PEA), a known substrate of the MAO-B enzyme.

    Method: Case Report

    Results: A 34-year-old male with history of major depressive disorder obtains selegiline tablets from an online pharmacy without a doctor's prescription for self-medication of mood symptoms. He takes selegiline 10 mg daily in combination with variable amount of PEA powder. Over a two-month period he begins to experience new onset daily panic attacks with palpitations, shortness-of-breath, nausea, dizziness, and feelings of impending doom. These panic attacks would also occur with facial flushing whenever the patient would have a beer. Concerned, he stops selegiline, but presents to the emergency department (ED) one week later for labile euphoric mood, racing thoughts, distractibility, and insomnia of three-day duration. In the ED he is hypertensive (164/104) and tachycardic (104). Laboratories are drawn which are normal with the exception of TSH 0.02 and a urinary drug screen positive for amphetamines. The patient is psychiatrically hospitalized for treatment of mood symptoms and substance abuse. Quetiapine is initiated for mood stabilization and treatment of insomnia which rapidly improves over 48 hours. The patient is discharged to chemical dependency treatment.

    Conclusions: Access to psychotropic medications via online pharmacies is poorly regulated. In this case, the patient experienced substance-induced panic attacks and a hypomanic episode from heightened levels of phenylethylamine from taking an MAO-B inhibitor in combination with this stimulant.

    References:

    1. Magyar K: The pharmacology of selegiline. Int Rev Neurobiol 2011; 100:65-84.

    2. Gibbons S: 'Legal highs'–novel and emerging psychoactive drugs: a chemical overview for the toxicologist. Clin Toxicol (Phila) 2012; 50(1):15-24.

    Objectives:

    1. To investigate the pharmacology and pathophysiology from the concomitant usage of an MAO-B inhibitor with a substrate of MAO-B, phenylethylamine.
    2. Analyze the implications of access to prescription medications via online pharmacies and the implications this has for patients and psychiatric practice.
    3. To foster an awareness of "legal highs" and the reactions they can have with prescription psychotropics.

    Relevance:
    This case highlights ethical, legal, and public safety concerns from psychotropics obtained online illegally without the guidance of a psychiatrist used in combination with legal stimulant-like substances.

     
  15. [T] Antidepressants and Bruxism: Review of Literature
    Presenting Author:  Natalia Ortiz
    Co-Author:  Harvinder Singh

    Introduction: Bruxism is an involuntary activity of the jaw musculature characterized by jaw clenching, bracing, gnashing, and grinding of the teeth while asleep [1]. Not only is bruxism more commonly a problem in individuals with depression and anxiety disorders, but also the medicines used to treat anxiety and depression can themselves often create a new iatrogenic or worsen a preexisting bruxism [2]. This article reviews the antidepressants known to cause bruxism and effective treatment reported in literature.

    Methods & Results: A total of 17 articles with a total of 26 individual case reports were obtained by manual and computerized literature search from January 1970 to March 2013. Relevant information was also derived from reference lists of the retrieved publications. Most cases of bruxism were attributed to venlafaxine (7) followed by fluoxetine (5), sertraline (5), paroxetine (3), citalopram (2), escitalopram (1), fluvoxamine (1), bupropion (1) and duloxetine (1). The most common reason was increase in the dosage of medications, and bruxism typically responded to buspirone (14 cases) followed by dosage reduction/discontinuation (6 cases), gabapentin (1 case), tandospirone (1 case) and electroconvulsive therapy (1 case).

    Conclusions: Based on this review, buspirone may be an effective treatment for the antidepressant-induced bruxism. The prevalence and pathophysiology of antidepressant-induced bruxism is unclear; however, disturbances in the central dopaminergic system, especially within the mesocortical tract, are linked to bruxism. Based on recent research, antidepressant-induced bruxism is considered to be a result of serotonergically mediated inhibition of the dopaminergic system [3]. Since Antidepressants are frequently prescribed medications, dentists should be aware of these side effects when assessing patients with bruxism. The diagnosis of antidepressant-induced bruxism can be challenging to make because it can present with such vague symptoms as bitemporal headaches, masseter tightness, or jaw pain in addition to the classic findings of tooth pain or frank tooth grinding. Prescribers may need to inquire specifically about these symptoms in order to elicit a history of underlying bruxism.

    References:

    1. American Academy of Orofacial Pain: Orofacial Pain: Guidelines for Assessment, Classification and Management. Chicago, Quintessence, 1996.

    2. Lobbezoo, et al: Reports of SSRI associated bruxism in the family physician's office. J Orofac Pain 2001; 15:340-346.

    3. Tanda, et al: Increase of extracellular dopamine in the prefrontal cortex: a trait of drugs with antidepressant potential? Psychopharmacology (Berl) 1994; 115:285-288.

    Objectives:

    1. To identify the correlations between bruxism, psychiatry disorders, and antidepressant medications.
    2. To identify the pathophysiology of the antidepressant-induced bruxism.
    3. To identify possible treatments for bruxism.

    Relevance:
    Bruxism is not only a manifestation of anxiety but is also correlated with the use of antidepressants. It can lead to temporomandibular joint disease impairing the mobility of the mouth.

     
  16. Serotonin Syndrome Following Discontinuation of Clozapine: A Case Report and Review of the Literature
    Presenting Author:  Elena Perea

    Purpose: Clozapine is often used in cases of symptom-resistant schizophrenia. It is a medication that is a dopamine antagonist, but has a low affinity for D-2 receptors as compared to other atypical antipsychotic medications [1]. However, it has a high affinity to a number of other receptors, including the 5HT2 receptor [2]. Serotonin syndrome is associated with agonism of that same receptor [3]. Clozapine withdrawal has been associated with cases of catatonia [4] and cholinergic toxicity, and one case of serotonin syndrome [5]. The case discusses a serotonin hypersensitivity after the discontinuation of clozapine, a 5HT2 antagonist.

    Methods: The author describes the history and condition of a 50 year old woman with schizoaffective disorder who developed mild serotonin syndrome. Symptoms included tachycardia, hyper-reflexia with mild clonus, anxiety and diarrhea in the context of clozapine discontinuation and low-dose doxepin initiation for insomnia.

    Results: The patient’s symptoms improved following discontinuation of doxepin and lowered dose of other serotonergic medications.

    Conclusions: Clozapine has a number receptor affinities that need to be carefully considered when titrating or discontinuing this medication, and when adding serotonergic medications to patients recently discontinued from a clozapine regimen.

    References:

    1. Potkin, et al: Challenges and solutions for developing new medications for schizophrenia. J Clin Psychiatry 2010; 71(10):1391-99.

    2. Fakra E, Azorin J: Clozapine for the treatment of schizophrenia. Expert Opin, Pharmacother 2012; 13(13):1923-35.

    3. Boyer EW, Shannon M: The Serotonin Syndrome. N Engl J Med 2005; 352:1112-20.

    4. Zerjav-Lacombe S, Dewan V: Possible serotonin syndrome associated with clomipramine after withdrawal of clozapine. Ann Pharmacother 2001; 35:180-182.

    5. Wadekar M, Syed S: Clozapine-withdrawal catatonia. Psychosomatics 2010; 51(4):355-355.e2.

    Objectives:

    1. Recognize complex pharmacodynamics of clozapine, and its effects on discontinuation.
    2. Recognize symptoms and signs of mild serotonin syndrome.
    3. Apply knowledge of serotonin syndrome to safe withdrawal of clozapine.

    Relevance:
    Clozapine can be a difficult medication to manage, and has a number of medical side effects requiring discontinuation. Withdrawal comes with some complications not often considered.

     
  17. Hyperprolactinemia as the Most İmportant Single Determinant of Sexual Dysfunction in Schizophrenia
    Presenting Author:  Burc Cagri Poyraz
    Co-Authors:  Cana Aksoy Poyraz, Armagan Ozdemir, Kemal Arikan

    Purpose: Antipsychotic treatment in schizophrenia is associated with sexual dysfunction, but the underlying mechanisms are poorly understood. Several explanations for this side effect have been proposed, however, such as the central, autonomic, and endocrine (mainly hyperprolactinemic) influences of antipsychotic agents. In this cross-sectional pilot study performed at Cerrahpaşa Medical Faculty in Istanbul between 2006 and 2007, we aimed to correlate the severity of sexual dysfunction in schizophrenia with levels of serum prolactin (PRL), age, severity of psychopathology, and depressive symptoms.

    Methods: Thirty-four randomly assigned clinically stable outpatients with the diagnosis of schizophrenia were included in the study. All patients were on stable doses of old and/or newer antipsychotics for at least three months at the time of interview and blood withdrawal for serum prolactin measurements. Severity of psychopathology was measured by the Brief Psychiatric Rating Scale (BPRS) and severity of sexual dysfunction by the Arizona Sexual Experience Scale (ASEX).

    Results: Participants’ mean age was 39.8, and female to male ratio was 7/27. Eighteen patients had abnormally high serum PRL levels according to the assay reference (cut-off for males: 18.4 ng/ml, and females: 24.1 ng/ml). Compared to normoprolactinemic patients, hyperprolactinemic patients had significantly higher scores in the items of ability to reach orgasm (p=0.03, Mann-Whitney), satisfaction with orgasm (p=0.005, Mann-Whitney) and total score of ASEX (p=0.003, Mann-Whitney). Correlational analyses between total ASEX score and each of the five ASEX items and age, BPRS (total, positive, negative and depressive symptomatology subscales) and serum PRL levels were also performed. Serum PRL levels were significantly correlated with total ASEX score (rs=0.56, p=0.001) and ASEX’s items of sexual desire (rs=0.4, p=0.01), satisfaction with orgasm (rs=0.4, p=0.01) and ability to reach orgasm (rs=0.55, p=001). Severity of psychopathology scores and age were not correlated with ASEX scores in our sample.

    Conclusion: Our results indicate that persistant hyperprolactinemia due to antipsychotic agents might be an independent and a strong determinant of sexual dysfunction in stable outpatients with schizophrenia.

    Objectives:

    1. Physician learners might find the topic interesting, since hyperprolactinemia having a straightforward negative effect on sexual function has not been yet well emphasized.
    2. A search for hyperprolactinemia in patients on antipsychotic agents might be warrented in case they report sexual dysfunction.
    3. The role of hyperprolactinemia in sexual dysfunction among psychiatric patient populations should be further investigated.

    Relevance:
    Antipsychotic agents are prescribed for numerous psychiatric conditions. One adverse effect of these agents is sexual dysfunction, the mechanism of which is not totally clear.

     
  18. [T] Correlation Between Chronic Pain and Depression in Veterans with PTSD versus Those without PTSD in a Clinical Population
    Presenting Author:  Jose Ribas Roca
    Co-Authors:  Nagy Youssef, Srini Pyati

    Aim: The aim of this study is to examine the correlation between chronic pain and depression in veterans with PTSD versus those without PTSD in a clinical population.

    Methods: We examined 182 patients presenting to the Durham VA Medical Center Chronic Pain clinic by clinical interview and physical examination, level of depression severity were assessed using Patient Health Questionnaire (PHQ-9). Pain severity was assessed with the Brief Pain Inventory (BPI); and pain interference with daily functioning was assessed with BPI-Interference subscale. Diagnosis of PTSD was made based on clinical interview. Statistical analyses using Pearson's correlation were performed to estimate the correlations between chronic pain and depression; as well as the correlations between chronic pain and pain interference with daily functioning in veterans with and without PTSD.

    Results: Results of the study show that correlates between depression and pain severity in patients with PTSD is 0.43 (p<0.0048) versus those without PTSD is 0.45 (p<0.0001). However, correlates between depression and pain interference with daily functioning in patients with PTSD is 0.62 (p<0.0001) versus those without PTSD is 0.66 (p<0.0001).

    Conclusions: Depression correlates with pain severity in a similar fashion in patients with and without PTSD. These results are unique in that there is higher correlation between depression severity and pain interference with daily functioning than between depression severity and pain (regardless of PTSD diagnosis). These findings have importance clinical and public health implications on the importance of addressing functional outcomes above and beyond control of symptoms in both clinical settings and in research design. This study warrants further replication in other populations.

    Objectives:

    1. Identify tools for psychiatric screening in primary care and pain clinics.
    2. Recognize relationship of pain and depression in veterans with PTSD compared to those without that diagnosis.
    3. Recognize differential effects in the pain interference scale in depressed veterans with PTSD compared to those without that diagnosis.

    Relevance:
    This paper provides further evidence for the need of integrated care in patients with chronic pain and psychiatric comorbitidy.

     
  19. [T] Increasing Incidence of Misdiagnosis of Psychiatric Disorders with Rising Use of Levetiracetam – A Thought to Address?
    Presenting Author:  Susana Sanchez
    Co-Authors:  Mahreen Raza, Rashi Aggarwal

    Introduction: Levetiracetam is a relatively new anti-epileptic agent developed for use as an adjunct agent in patients with partial epilepsy, also approved as adjunctive therapy in treatment of adults and adolescents with juvenile myoclonic epilepsy.

    Controlled clinical trials have reported a wide margin of tolerability. Its 100% biological availability, linear kinetics, and no drug-to-drug interaction, make it a good candidate drug. Although it has benign, infrequent, mild side effects, psychiatric adverse effects have been reported. Here we present a case of a 48-year-old male with psychosis secondary to the levetiracetam use and its resolution after the discontinuation of the medication.

    Case Report: A 48-year-old male with a history of seizure disorder secondary to a traumatic brain injury was started on levetiracetam at a dose of 500 mg twice a day for seizure control. The patient had no history of psychiatric illness, inpatient hospitalizations, or suicide attempts. One week after starting levetiracetam, he began having auditory hallucinations of dogs barking at different times during the day as well as a change in his behavior and cognition, including confusion and disorientation. Patient was having persecutory delusions and poor response to social contact. However, the patient was seizure free. Psychiatry was consulted recommending discontinuing levetiracetam. After two days of discontinuation his symptoms resolved. During the following 4 months he presented with no evidence of recurrence of psychosis.

    Discussion: Multiple new anticonvulsants have been introduced recently supplanting the older medications, but the properties of the newer ones are unique and largely unknown.

    A study on levetiracetam effectiveness found behavioral side effects occurred in 26 patients of a total of 78: irritability and impulsiveness in 21, psychiatric episodes in 3 and confusion warranting discontinuation of the drug in 2. After review of the medical history it was found that 10 of the patients with behavioral side effects have had behavioral problems in the past.

    As described in our case, levetiracetam may lead to various psychiatric adverse effects including psychosis and change in behavior. Close clinical monitoring with regard to psychiatric adverse events is needed when starting treatment, as well as exploration about advantages and disadvantages especially on patients with risk factors. The slightest indication of emergence of side effects should lead to psychiatric consultation.

    Objectives:

    1. To educate about the neuropsychiatric side effects of levetiracetam and the probability of misdiagnosis of psychiatric disorders.
    2. To educate about probable misdiagnosis of psychiatric disorders.
    3. To learn about stratified risk assessment before using levetiracetam in psychiatric patients.

    Relevance:
    As described, levetiracetam may lead to various psychiatric adverse effects. We are hoping this case and literature review help the psychiatrist and neurologist to identify side effects mimicking psychiatric diagnosis.

     
  20. [T] Support for the Use of Clozapine in the Treatment of Psychogenic Polydipsia in a Non-Psychotic Patient: A Case Study
    Presenting Author:  Amanda Spray
    Co-Authors:  Inci Bijan, Brian Bronson

    Purpose: There is a paucity of research describing the effective pharmacological treatment of psychogenic polydipsia, especially in patients who do not present with schizophrenia. This case study illustrates a rare case of polydipsia that was successfully treated with clozapine and strongly supports the use of clozapine in psychogenic polydipsia.

    Methods: The patient was hospitalized on a medical unit for 57 days where sodium levels were closely monitored. A one-to-one restriction was placed for excessive water consumption and data regarding days on and off this restriction were collected. Mental status exams were completed by the consultation-liaison team three times weekly. The patient underwent psychodiagnostic testing including administration of the Rorschach Inkblot Test and the Personality Assessment Inventory (PAI).

    Results: The patient was admitted with Na levels of 109, requiring ICU admission. Initially, the patient failed trials of risperidone and aripiprazole. The patient was started on clozapine 25mg, titrated up to 200mg daily. Sodium increased to 139 and subjective reports of cravings for water decreased over the clozapine trial. However, after 10 days of treatment, clozapine was suspended due concerns regarding an adverse drug reaction after the patient developed fever, eosinophilia, and tachycardia. Extensive medical work up ruled out potential complications of clozapine, including myocarditis. While off of clozapine, the patient's water consumption greatly increased. During this time the pt underwent psychodiagnostic testing to clarify diagnosis. The PAI evidenced significant elevations in depression (T = 80) and anxiety (T = 74). While he evidenced factors suggesting social isolation (T = 76) and some thought disorganization (T = 67), his profile was not suggestive of psychosis or consistent with a diagnosis of schizophrenia. Projective testing showed a similar patterns and suggested Axis II psychopathology. A clozapine rechallenge was initiated and the dose was titrated up to 75mg daily, with good response. The patient once again showed a steady decline in water consumption, improved range of affect, and was able to be discharged to his prior place of residence.

    Conclusions: This case study highlights that doses of clozapine that are lower than that usually used to treat schizophrenia may be effective in treating psychogenic polydispia in a non-psychotic patient. Based on the existing literature and supported by the case described, further research regarding the efficacy of clozapine in the treatment of psychogenic polydipsia is warranted.

    References:

    1. De Leon J, Verghese C, Stanilla JK, Lawrence T, Simpson G: Treatment of polydipsia and hyponatremia in psychiatric patients. Can clozapine be a new option? Neuropsychopharmacology 1995; 12 (2):133-138.

    2. Spears NM, Leadbetter RA, Shutty MS: Clozapine treatment in polydipsia and intermittent hyponatremia. J Clin Psychiatry 1996; 57(3):123-8.

    Objectives:

    1. Investigate the potential benefit of using clozapine for the treatment of psychogenic polydipsia in a non-psychotic patient.
    2. Apply our clinical case report results to patients that may present in clinical practice.
    3. Inform clinical trials in the future regarding the use of clozapine in the treatment of psychogenic polydipsia.

    Relevance:
    This case study highlights that doses of clozapine that are lower than that usually used to treat schizophrenia may be effective in treating psychogenic polydispia in a non-psychotic patient.

     
  21. WITHDRAWN
     
  22. [T] Psychosis by Design: Considering the Effects of Synthetic Cathinones and Cannabinoids
    Presenting Author:  Gerald Winder
    Co-Authors:  Bradley Stilger, Avinash Hosanagar

    Recreational drug use is a common etiology for psychotic symptoms evaluated by emergency and hospital psychiatrists. Established drug classes such as hallucinogens and amphetamines have long been documented as possible causes of psychosis; however, the latest drug trends are always evolving. Two newer classes of recreational "designer drugs"—synthetic cathinones and synthetic cannabinoids—can both cause psychosis and have recently grown in popularity. The consulting psychiatrist may be asked to assess a patient who has recently used one of these drugs and has undergone medical workup and toxicological screening, which often yields inconclusive results in this setting. The toxidromes of these drugs are unique and they are not detected on routine urine drug screen.

    We present two clinical cases that depict the link between these drugs and the incidence of psychosis. We include a review of what is known about their pharmacology and effects on human neurophysiology while describing methods of their detection utilizing both physical examination and laboratory assay. There are considerable gaps in our understanding of these drugs and we suggest future areas of research. This information will further equip the hospital psychiatrist with the awareness required to broaden the differential diagnosis of psychosis to include the presence of these "designer drugs" during an evaluation.

    References

    1. Fass JA, Fass AD, Garcia AS: Synthetic cathinones (bath salts): legal status and patterns of abuse. Ann pharmacotherapy 2012; 46(3):436-441.

    2. Gunderson EW, Haughey HM, Ait-Daoud N, Joshi AS, Hart CL: "Spice" and "K2" herbal highs: a case series and systematic review of the clinical effects and biopsychosocial implications of synthetic cannabinoid use in humans. Am J Addict 2012; 21(4):320-326.

    3. Hudson S, Ramsey J: The emergence and analysis of synthetic cannabinoids. Drug Test Anal 2011; 3(7-8):466-478.

    4. Prosser JM, Nelson LS: The toxicology of bath salts: a review of synthetic cathinones. J Med Toxicol 2012; 8(1):33-42.

    5. Vardakou I, Pistos C, Spiliopoulou C: Spice drugs as a new trend: mode of action, identification and legislation. Toxicol Lett 2010; 197(3):157-162.

    6. Winder GS, Stern N, Hosanagar A: Are "bath salts" the next generation of stimulant abuse? J Subst Abuse Treat 2012; 44(1):42-45.

    Objectives:

    1. Understand the general physiology of synthetic cannabinoids and cathinones.
    2. Investigate the causes of psychosis including a wider differential diagnosis.
    3. Utilize available lab assays to properly screen for use of synthetic cathinones and cannabinoids.

    Relevance:
    Recreational drugs are a common etiology of psychosis evaluated by consult psychiatrists. Drug trends always evolve and two new, popular classes of synthetic agents (cathinones and cannabinoids) can cause psychosis.

     

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Section H:  Systems-Based Practice

  1. Are Patients with Severe and Persistent Mental Illness Responsible for the Perpetration of Violence Towards Care Providers on Medical-Surgical Floors? A Retrospective Chart Review
    Presenting Author:  Kristine Beard
    Co-Author:  Lisa Seyfried

    Background:A central understanding of consultation-liaison psychiatrists is the fact that untreated or under-treated mental illness within the general hospital is correlated with worse patient outcomes than the general medical population. Studies have estimated the prevalence of mental illness on medical-surgical units to be as high as 40%. Consequently C-L psychiatry strives to ensure that medical-surgical colleagues have access to rapid, high quality, psychiatric assessment and treatment. An important component of this process is the timely identification and treatment of patients who demonstrate behavioral agitation, verbal aggression, or physical violence towards care providers. When care providers are threatened or injured, difficult questions are often raised. At the University of Michigan Health System, hospital administration asked whether or not patients with severe and persistent mental illness were more likely to engage in violence against care providers than patients without such diagnoses.

    Objective:Workplace violence is a significant concern among health care providers. Much of the literature on this topic has focused on identified ‘high risk' areas such as emergency departments. Little is known about violent acts and threats in the general hospital. The purpose of this study was to learn more about perpetrators of hospital workplace violence/threats. We aimed to collect demographic, situational and clinical information about perpetrators and their acts/threats of violence in the general hospital.

    Methods: A retrospective chart review was conducted of all psychiatric consultations that included "agitation", "aggression" and/or "behavior" seen in a three-month period. In addition we reviewed hospital incident management records and security logs describing workplace violence over that same three month period.

    Results: Of the total 1068 consults seen in a year, 69 were for "agitation", "aggression" and/or "behavior" Of those 69, 34 were included in our detailed chart review. Delirium was the most common diagnosis, accounting for 67% of the consults. During that same time period, a review of security logs, police reports, incident reports and security logs revealed 75 total threats or incidents of violence. Of those, only 7 incidents of physical harm or attempted harm occurred in the general hospital. Review of patient records revealed the majority of perpetrators had delirium (86%).

    Conclusion: Our work suggests that patients who are delirious are the most common perpetrators of violence in the general hospital. This information is of critical importance in our continuing efforts to develop more robust intervention and prevention programs. In addition, this finding serves to educate others and reduce the stigma of violence often associated with patients with severe and persistent mental illness.

    Objectives:

    1. Recognize the role of C-L psychiatry in mitigating patient perpetrated workplace violence towards care providers.
    2. Identify the most common diagnosis associated with behavioral agitation and violence in the general hospital.
    3. Appreciate the ability of C-L psychiatry to participate in quality improvement activities at an academic medical center.

    Relevance:
    Understanding factors associated with workplace violence is clinically and institutionally valuable. This poster, evaluating demographic, situational and clinical information about perpetration of violence in the hospital, will inform clinical practice.

     
  2. [T] Feasibility of Medical Monitoring in a Community Psychiatry Clinic
    Presenting Author:  Hannah Brown
    Co-Authors:  Sarah MacLaurin, David Henderson, Oliver Freudenreich

    Purpose: Patients with severe mental illness have increased medical morbidity and mortality compared to the general population. This increase in morbidity and mortality is partly due to lifestyle choices, iatrogenic morbidity, and substandard medical care; cardiovascular disease is the most frequent cause of death in this population [1,2]. It is critical for psychiatrists to facilitate medical monitoring and care in this vulnerable population [3]. Our goal was to establish a standardized monitoring system for metabolic parameters, medical co-morbidities, and quality of life measurements in a community psychiatric setting, with the goal of addressing modifiable risk factors.

    Methods: We created a medical-psychiatric referral clinic located in our community mental health center. Patients were specifically referred to this clinic for focused visits that included measurement of the following: vital signs, BMI and waist circumference, blood work (screening for metabolic parameters including fasting lipid profile and glucose), a focused physical exam (screening for extrapyramidal symptoms and tardive dyskinesia (TD)), and documentation of medical status including the use of standardized scales (AIMS to screen for TD, Fagerstrom test for nicotine dependence, AUDIT-C for screening of alcohol use, WHO Quality of life). Contact was made with patient’s PCP if indicated. We piloted this program predominantly in our young patients with psychosis population in order to initiate standardized medical monitoring early in their illness course. We considered this a high-risk population where early medical intervention is critical for improved long-term health outcomes.

    Results: We have found implementation of this medical-psychiatric clinic to be feasible. All patients reported fasting for approximately twelve hours prior to the clinic visit. We were able to identify barriers that can hinder successful medical monitoring and care in this population, including patient’s limited contact with PCP, missed clinic appointments, our clinic’s limited access to a phlebotomist, and clinicians’ time constraints.

    Conclusions: We propose a standardized method for psychiatrists to integrate aspects of primary care into mental health community clinics; specifically basic medical screening and documentation. Once a monitoring system is successfully established, appropriate treatment interventions can be more easily implemented, and population-based management becomes possible.

    References:

    1. Vanderlip ER, Fiedorowicz JG, Haynes WG: Screening, diagnosis, and treatment of dyslipidemia among persons with persistent mental illness: a literature review. Psychiatr Serv 2012; 63:693-701.

    2. Nasrallah H, Meyer JM, Goff DC, et al: Low rates of treatment for hypertension, dyslipidemia and diabetes in schizophrenia: data from the CATIE schizophrenia trial sample at baseline. Schizophr Res 2006; 86:15-22.

    3. Wiechers IR, Freudenreich O: The role of consultation-liaison psychiatrists in improving health care of patients with schizophrenia. Psychosomatics 2013; 54:22-27.

    Objectives:

    1. Recognize the excess morbidity and mortality in patients with severe mental illness and importance of relevant monitoring.
    2. Consider implementing a standard set of monitoring parameters in a community psychiatry clinic.
    3. Apply population-based management in a community mental health clinic.

    Relevance:
    Developing a system to integrate primary care and appropriate medical monitoring for patients with severe mental illness is of extreme importance in our increasingly fractured healthcare system.

     
  3. [T] Development and Implementation of a Standardized Alcohol Withdrawal Protocol for Psychiatric Inpatients
    Presenting Author:  Michael Butterfield
    Co-Author:  Nicole Herschenhous

    Purpose: Alcohol use disorders are highly comorbid with other psychiatric disorders with lifetime co-occurrence rates of 56% to 86%. Of alcohol-related syndromes, alcohol withdrawal is one of the most serious as it can result in significant morbidity and mortality. While there have been numerous studies showing the positive effect of instituting protocols to decrease the morbidity associated with alcohol withdrawal syndrome (AWS) in medical and surgical wards, to date there have been very few studies that investigate the efficacy of these protocols in inpatient psychiatric wards. While the current gold standard for symptom-triggered treatment of AWS is the use of the CIWA-Ar, patients being treated primarily for psychotic, mood, and/or anxiety disorders often exhibit a number of symptoms such as hallucinations, delusions and elevated levels of anxiety that complicate the interpretation or even preclude the use of the CIWA-Ar scale. To more effectively managing AWS in these complex patients, we developed a treatment algorithm for AWS targeting the specific needs of these patients, with input from a multidisciplinary team. We hypothesize that the development of a coherent and evidence-based treatment algorithm, along with modification of the application of the CIWA-Ar to include more objective assessment methods for patients with severe psychotic, mood, and/or anxiety disorders will result in more accurate assessments and improved outcomes in this population.

    Methods: We performed a literature review to identify the current evidence for inpatient treatment of AWS with a specific focus on psychiatric inpatient populations. We then developed treatment algorithm using this evidence base and the clinical experience of a multidisciplinary mental health team. After implementation of this algorithm, we plan to compare outcomes between patients admitted to psychiatric inpatient units who are at risk of AWS before and after the implementation of this treatment algorithm. The primary outcome will be duration of benzodiazepine treatment for alcohol withdrawal. Secondary outcomes will be cumulative benzodiazepine dose administered, and incidence of complications.

    Results: We will describe the results of our literature review, along with the process of gathering and incorporating input from nursing, psychiatry, medicine, and pharmacy in the Psychiatric Emergency Service, Short Stay Unit (an extension of the psychiatric emergency service), and psychiatric inpatient units at the QEII Health Sciences Center. We will also describe the decision-making process regarding development of the treatment algorithm. We will then review the results of the planned study to examine the effect of implementation of this treatment algorithm on patient care.

    Conclusions: Development of a standardized treatment protocol for alcohol withdrawal in patients admitted for non-addiction disorders to a psychiatric facility requires strong interdisciplinary collaboration. We will discuss conclusions regarding the impact of the protocol implementation on clinical care in these three settings.

    Objectives:

    1. Recognize challenges in treating alcohol withdrawal syndrome in psychiatric inpatients.
    2. Describe current interdisciplinary approaches to the development of treatment protocols.
    3. Describe the impact of using objective assessment methods for the treatment of alcohol withdrawal in patients with comorbid psychiatric disorders.

    Relevance:
    This presentation highlights and attempts to address the paucity of data concerning the treatment of alcohol withdrawal syndrome in patients whose psychiatric comorbidities influence the interpretation of current treatment algorithms.

     
  4. Vitamin D Deficiency and Depression in Primary Care Patients
    Presenting Author:  Yi Cai
    Co-Authors:  Maria Lapid, Steven Cha, Paul Takahashi

    Introduction: Vitamin D deficiency is very common in the United States. It has been linked to depression, although studies have been inconclusive. We investigated vitamin D levels in primary care patients and explored associations with depression.

    Methods: We conducted a retrospective study of 2,568 patients empaneled primary care patients at a large academic medical center with PHQ-9 scores and serum total 25-hydroxyvitamin D (25(OH)D) levels within one year apart. Measures of frailty (Elder Risk Assessment, ERA) and medical comorbidity (Charlson Comorbidity Index, CCI) were also collected. Data were summarized with frequency, percentages, and mean. Association analyses were performed.

    Results: There were 2,568 patients with a mean age of 50.8 years (SD 17.2, range 12-97), and a mean PHQ-9 score of 6.5 (SD 6.4, range 0-27). Majority (n=1,882, 73%) had optimal (≥25 ng/mL) 25(OH)D levels, however, 25% (n=637) had mild-moderate (10-24 ng/mL) and 2% (n=49) had severe (<10 ng/mL) 25(OH)D deficiencies. Vitamin D level was negatively correlated with PHQ-9 (r=-0.04, P=0.03), and positively correlated with age (r=0.13, P<0.001) and CCI (r=0.05, P=0.02). Multivariate regression model demonstrated vitamin D level and PHQ-9 were not correlated after adjustment for age (P<0.0001) and ERA score (P<0.0001).

    Conclusions: Vitamin D deficiency was present in over one-fourth of this primary care population. Lower vitamin D level was correlated with higher depressive symptoms. However, in the fully adjusted analysis when age and frailty scores were taken into account, no differences in depressive scores were seen among vitamin D level categories.

    Objectives:

    1. Define vitamin D deficiency and appreciate the prevalence of vitamin D deficiency in primary care patients.
    2. Analyze factors involved in depression as true factors or as confounders.
    3. Define elements contributing to depression to enhance detection of the disorder in the indicated subpopulation.

    Relevance:
    To improve quality of care, it is our professional commitment to understand the efficacy of managements that may or may not augment current treatment strategies of mental health disorders.

     
  5. Positive Psychological States in Diabetes: Impact, Mechanisms, and Potential Treatment Targets
    Presenting Author:  Christopher Celano
    Co-Authors:  Eleanor Beale, Shannon Moore, Jeff Huffman

    Purpose: Diabetes mellitus (DM) is common—occurring in 11% of US adults over the age of 20—and has been associated with impaired functioning, cardiovascular and cerebrovascular complications, and increased rates of mortality. Psychological states may significantly impact outcomes in patients with DM. Depression is highly prevalent in this cohort and has been associated with poor dietary adherence, poor glucose control, increased diabetes-related complications, and mortality. Positive psychological states such as optimism and resiliency likely impact this population as well. However, there has been minimal systematic review of these states and their associations with psychiatric and medical outcomes in these individuals. Accordingly, we aim to review the literature related to positive psychological states in this high-risk cohort.

    Methods: We will provide a comprehensive review of the literature focusing on positive psychological states and their associations with adherence, morbidity, and mortality in patients with DM. Then, drawing from the literature of these states in other medically ill populations, we will elucidate potential mechanisms that may mediate the relationships between positive psychological states and poor medical outcomes. Finally, we will review the evidence for treatments that may impact positive psychological states in this cohort.

    Results: Positive psychological states are significantly associated with improved outcomes in individuals with and without DM. In healthy individuals, these states have been associated with increased mobility, better functional status, lower rates of metabolic syndrome, and lower rates of mortality. In individuals with DM, positive psychological states such as resiliency, positive affect, self-efficacy, and optimism have been associated with improved outcomes, such as lower glycosylated hemoglobin levels, lower rates of diabetic complications, and reduced rates of mortality. Potential mechanisms mediating these associations include behavioral factors (e.g., improved diet, improved adherence to treatment, increased exercise), reduced rates of inflammation, and improved endothelial and autonomic functioning. Most psychosocial treatments in patients with DM have focused on empowerment, increasing social supports, and providing education about DM and its management; such interventions have been found to improve quality of life, well-being, and diabetes self-care. However, interventions that focus specifically on improving positive psychological states have largely been untested in this population.

    Conclusions: Positive psychological states are associated with improved outcomes in patients with and without DM, and these improvements may be mediated by a number of behavioral and physiologic mechanisms. Interventions aimed at improving positive psychological states in DM patients may represent an innovative treatment modality that can help to optimize management of this debilitating condition.

    Objectives:

    1. Describe the relationship between positive psychological states and outcomes in patients with diabetes mellitus.
    2. Identify potential mechanisms mediating the relationship between positive psychological states and outcomes in patients with diabetes mellitus.
    3. Identify potential treatments that target positive psychological states in patients with diabetes mellitus.

    Relevance:
    This presentation will comprehensively review the associations between positive psychological states and outcomes in patients with diabetes and will highlight the importance of identifying/strengthening these states in this high-risk cohort.

     
  6. Collaborative Care with a Trauma Center Surgery Service: Assessing and Reducing Risk of Violent Re-injury among Victims of Urban Violence
    Presenting Author:  Erich Conrad
    Co-Authors:  John Nanney, Joseph Constans

    Objective: Victims of urban violence face adversity beyond their acute physical injuries. For many, violent trauma is a recurrent event, with up to 44% of urban violence victims experiencing later hospitalizations due to another intentional injury. The victims often have histories of violence perpetration themselves, and there is a heightened risk for violence following the injury. Given these factors, collaborative care interventions to reduce the risk of violence perpetration and violent re-injury may be vitally important for this patient population at trauma centers.

    Motivational Interviewing (MI) may be a particularly promising intervention for encouraging violently injured patients to take action to reduce their risks. MI has not yet been evaluated as a brief intervention for critically injured adults who may be at highest risk for violence and violent re-injury.

    Methods: A single-group, within-subjects longitudinal design is employed for this pilot study. Enrollment, baseline assessment, and the motivational interview occur during the patient's hospitalization. Patients are then followed prospectively for three months post-discharge.

    Results: Up-to-date pilot data will be presented. Results will describe the sample at baseline and report initial evidence of change in outcome variables over time.

    Conclusions: Collaborative care with trauma center surgery services may allow for an opportunity to impact the outcome of violence and potential violent re-injury among victims of urban violence.

    Objectives:

    1. Be able to discuss the relevance of violence prevention with trauma center populations.
    2. Appreciate the obstacles in reaching this often difficult group of patients.
    3. Analyze the pilot data thus far collected in an intervention to help reduce risk of violent reinjury in trauma center patients.

    Relevance:
    Consultation psychiatrists who work with violently injured patients may be able to apply this knowledge to their own practice

     
  7. Family-Centered Care for Traumatically Injured Patients: Lessons Learned from Combat Injured Families
    Presenting Author:  Stephen Cozza
    Co-Authors:  Allison Holmes, Susan Van Ost

    Purpose: This presentation will highlight the importance of family-focused approaches to the clinical care of traumatically injured patients.

    Methods: The impact of combat injury on military service families will be described, to include a review of clinical experience and empirical data. Special emphasis will be placed on understanding the impact of injury on family relationships, both intimate partnerships and parent-child relationships. Relevant topics including injury impact on family functioning, parenting practices and relationship intimacy, as well as the application of developmental principles will be highlighted. A model program to address family distress and support healthy functioning will be described. The application of these lessons learned to civilian practice will be discussed.

    Results: Over 50,000 military service members have been injured since the start of combat operations in Iraq and Afghanistan. The relatives of these survivors are left to cope with their loved one’s extensive injuries, long-term recovery, permanent disability, and changed behavior. Protecting and ensuring the behavioral health of these families is key to injury rehabilitation and to prevention of mental health problems in all family members. The following strategies have been developed to support the mechanisms likely to promote family equilibrium and resilience under the stress of combat injury and its sequelae: (1) reduce family distress and disorganization and provide instrumental support; (2) develop emotion regulation skills necessary for ongoing dialogue and collaboration; (3) educate adults and children about the impact of injury and the expected recovery process; (4) promote helpful and ongoing communication about the injury that incorporates developmentally appropriate language; and (5) encourage optimism through development of successful problem solving, newly required modes of interaction and shared future goals.

    Conclusions: Work with combat-injured families has resulted in successful family-focused strategies for the traumatically injured. These principles can be effectively applied to civilian populations where serious traumatic injury (e.g. motor vehicle accidents, occupational injuries) is common.

    References:

    1. Cozza SJ, Guimond JM, McKibben JBA, Chun RS, Ursano RJ: Combat-injured service members and their families: The relationship of child distress and spouse-perceived family distress and disruption. J Traumatic Stress 2010; 23(1):112-115.

    2. Cozza SJ, Guimond JM: Working with Combat-Injured Families Through the Recovery Trajectory. In MacDermid Wadsworth S, Riggs D (eds): Risk and Resilience in US Military Families. New York: Springer, 2011, pp. 259-277.

    3. Gorman LA, Fitzgerald HE, Blow AJ: Parental combat injury and early child development: a conceptual model for differentiating effects of visible and invisible injuries. Psychiatry Quarterly 2010; 81:1-21.

    4. MacDermid Wadsworth S, Lester P, Marini C, Cozza SJ, Sornborger J, Strouse T, Beardslee W: Approaching family-focused systems of care for military and veteran families. Military Behavioral Health 2013; 1:1-10.

    Objectives:

    1. Incorporate family evaluation strategies to understand injury impact, levels of distress and risk within the traumatically injured population.
    2. Employ developmentally appropriate language in building communication strategies within families with young children.
    3. Utilize family-focused strategies to build strength and resilience traumatically injured patient families.

    Relevance:
    Serious traumatic injury occurs commonly in the United States. Family health and functioning can be powerfully impacted and often are unaddressed. Strategies from this presentation can be effectively applied.

     
  8. [T] Mental Health Access and Care Transition Challenges in the Primary Care Population: Results of a Pilot Psychiatric Assessment and Care Transition (PACT) Clinic
    Presenting Author:  D. Edward Deneke
    Co-Authors:  Lindsey Mortenson, Thomas Fluent

    Purpose: Psychiatric care is currently delivered across multiple service sectors, most commonly general medicine, specialty mental health, and self-help programs. In the general medical setting, health services research has demonstrated that patients often receive treatment that is below the minimal threshold of adequacy defined by evidence-based guidelines. The Affordable Care Act (ACA) and various health policy initiatives are attempting to address this issue by promoting healthcare delivery models that emphasize collaboration between primary care and specialty mental health providers, as well as disease prevention and mental health wellness. To address similar issues within our academic health system – in which patients may wait up to 16 weeks for an initial psychiatric evaluation, and in which the “one-time” specialty consultation model often fails to meet the needs of patients and primary care providers – the authors are piloting a novel Psychiatric Assessment and Care Transition (PACT) clinic.

    Methods: Adult patients scheduled for evaluation in the PACT clinic meet the following criteria: (i) referral from a primary care physician in our health system; (ii) availability for the same weekly timeslot for initial and return appointments (e.g., Friday 8am-noon), and (iii) not better suited for initial evaluation in one of our specialty psychiatric clinics (e.g., Perinatal, Addiction Treatment Services). The total time allotted for the initial evaluation is 90 minutes: 60-75 minutes for evaluation, psycho-education, and treatment recommendations; 15-30 minutes for documentation and care collaboration. Patients are evaluated by a fourth-year psychiatry resident during a half-day elective dedicated to the PACT clinic. A standard evaluation template is used that includes treatment recommendations for pharmacotherapy, psychotherapy, education, behavioral changes, and follow-up. Patients are instructed about the goals of the clinic to offer treatment recommendations and safely transition care to one of the many available service sectors. Emphasis is placed on the importance of the patient taking an active role in their care and collaborating with the treatment team. Patients are scheduled for return visits as needed.

    Results: Official results are pending further implementation of the clinic. To date, the clinic has scheduled nine initial patient evaluations. We anticipate that the average number of total visits per patient in the clinic will be approximately 3-5 appointments before transition out of the clinic.

    Conclusions: The authors hope that this pilot clinic will achieve the goals of increasing access to psychiatric care; improving collaboration between patients, primary care and specialty mental health care providers; and promoting mental health wellness. If successful, we hypothesize that this clinic model could evolve into a team clinic, to include faculty psychiatrists and psychologists, staff social workers and nurse practitioners, and advanced trainees with the expertise to efficiently evaluate patients, initiate appropriate treatment, and safely transition care to the appropriate setting.

    Objectives:

    1. Develop new delivery mechanisms for mental health care in the ambulatory psychiatry setting that exceed the minimum threshold of adequate care.
    2. Explore ways to deliver innovative care that encourage patients to take an active and collaborative role in their mental health.
    3. Understand the goals of the ACA and various health policy initiatives with respect to collaboration between primary care and specialty mental health care providers.

    Relevance:
    This presentation will be relevant for psychiatrists in treatment settings where mental health access is limited and where there is increased interest in effective and efficient collaboration with primary care.

     
  9. Collaborative Approach Utilizing Behavioral Activation to Treat Pain and PTSD in Returning Veterans
    Presenting Author:  Steven Dobscha
    Co-Authors:  Jane Plagge, Mary Lu, Travis Lovejoy, Andrea Karl

    Objective: We describe preliminary outcomes of a clinical demonstration project utilizing collaborative care components and behavioral activation (BA) to treat comorbid chronic pain and posttraumatic stress disorder (PTSD).

    Participants and Design: Fifty-eight veterans of Iraq and Afghanistan with chronic pain and PTSD symptoms from a single VA Medical Center participated in a biopsychosocial evaluation and up to 8 BA sessions. In addition, a physiatrist assisted a psychologist in providing recommendations to primary care providers; common recommendations included physical therapy, exercise, pain medication or pain medication adjustments, and additional diagnostic work up, such as imaging. Completers were compared to noncompleters, and for intervention completers, generalized estimating equations were used to model changes in PTSD symptoms, pain severity, pain interference, mood, pain catastrophizing, kinesiophobia, life satisfaction, quality of life, and alcohol use over time.

    Findings: Thirty (52%) veterans completed treatment. Completers were all male, and the majority were white, non-Hispanic (87%), married (57%) and, on average, had completed one year of college. Seventy-seven percent had VA service-connected disabilities. Fifty percent had diagnoses of traumatic brain injury and 83 percent had two or more chronic pain diagnoses. Completers were significantly older than noncompleters (Mean 38.8 vs. 30.1 years, p = 0.016) but did not differ on other demographic, disability, or pain diagnosis variables.

    Program completers showed significant improvements on measures of PTSD (PTSD Checklist mean pre: 63.4, post: 54.6, Wald Chi Square=17.20, p <0.001), pain severity (Chronic Pain Grade (CPG) Severity mean pre: 6.8, post: 5.8, Wald Chi Square=5.95, p=0.050), and pain interference (CPG Interference Mean pre: 6.9, post: 4.9, Wald Chi Square=22.52, p <0.001) with the greatest improvements occurring from pre- to mid-intervention. There were also significant improvements on measures of mood, pain catastrophizing, fear avoidance, life satisfaction, and quality of life. Twenty percent of intervention completers (n=6) experienced clinically significant reductions (defined as 30% reduction) in pain severity, while 40% (n=12) experienced clinically significant reductions in pain interference. Participants overall were satisfied with the program and, on average, reported feeling somewhat better.

    Conclusions: These preliminary findings suggest that a collaborative approach which includes BA is feasible and a potentially effective treatment for comorbid chronic pain and PTSD. Because communication between disciplines usually occurred through chart documentation, email, or telephone, the intervention has potential to be implemented in a variety of settings when a specialized multidisciplinary pain clinic or PTSD clinic is not available. Given that retention was limited and that the greatest improvements occurred by mid-treatment, a briefer version of the program should be explored in attempt to improve retention and reduce cost.

    Objectives:

    1. Describe prevalence and impacts of comorbid pain and PTSD.
    2. Investigate integrated clinical approaches to comorbid pain and PTSD.
    3. Apply knowledged gained to clinical practice with patients with comorbid pain and PTSD.

    Relevance:
    Comorbid pain and PTSD are common and are associated with greater morbidity and disability than either condition alone. Collaborative care and behavioral activation show promise for treating these comorbid conditions.

     
  10. Comparison of Compliance by Medical and Psychiatric Patients Presenting to an Emergency Department
    Presenting Author:  Lavonne Downey

    Introduction: The purpose of this study was to examine what, if any, differences exist between non-compliant medical and psychiatric patients regarding sources of medical care, affordability of and access to medications, and reasons for non-compliance.

    Methods: A convenience sample of patients with medical or psychiatric complaints who presented to the emergency department of an inner-city, level 1 trauma center (60,000 annual visits) and stated they were non-compliant with their medications were enrolled in this IRB approved study. Inclusion criteria: age ≥ 18, English-speaking, medically stable, able to give informed consent, non-compliant with medications. A 45-question survey consisting of questions from the validated National Health Access Survey [9] along with a demographic profile were administered by a research fellow. The survey asked about sources of medical care as well as reasons for non-compliance such as access and cost of health care/medications.

    Results: A total of 160 patients were enrolled, 60 medical and 60 psychiatric. There was no significant difference between the two populations in regards to their survey results. 20% of medical and 35% of psychiatric patients do not go anywhere for preventative care. 14% of medical and 10% of psychiatric patients do not have a usual source of healthcare because they cannot afford.

    Access to Medical Care (in regards to the past 12 months): 75% of medical and psychiatric patients did not have trouble finding a general doctor who would see them. 50% of medical and 65% of psychiatric patients stated they delayed getting care because they did not have transportation.

    Affordability of Medical Care (in regards to the past 12 months): 70% in both groups stated they did not get prescription medications because they could not afford it. 57% of medical and 53% of psychiatric patients stated they needed mental care but could not afford it. 46% of medical and 67% of psychiatric patients stated they needed follow-up care but could not afford it.

    Non-compliance to Medications: 49% of medical and 44% of psychiatric patients stated that their main reason for non-compliance to medications was due to inability to afford the cost of medications.14% of medical and 25% of psychiatric patients stated they were unable to comply with their medication regimen because they ran out of refills. 17% of medical patients stated they forgot to take their medications. 9% of medical and 13% of psychiatric patients said that they did not get around/put off taking

    Conclusion: When comparing noncompliant medical and psychiatric patients, we found that there were no statistically significant differences between the two populations in regards to their answers to the National Health Access survey questions. In regard to accessibility/affordability of health care and medications, medical and psychiatric patients did not differ in their reason for non compliance.

    Objectives:

    1. To understand how psychiatric patient compliance compares to medical patients.
    2. To learn why psychaitric patients are non-compliant.
    3. To comprehend what is needed to improve patient compliance.

    Relevance:
    Patient compliance is an essential issue for psychiatric patients. It is important to understand the reason for non-compliance.

     
  11. Improving Mental Health Screening for Youth with Epilepsy: An Increased Coordination of Care Strategy to Improve Quality of Life
    Presenting Author:  Tatiana Falcone
    Co-Authors:  Elia Pestana, Jane Timmons-Mitchel, Prakash Kotagal

    Purpose: 1) To describe the development and implementation of mental health screening in a pediatric epilepsy clinic that improved care coordination for mental health problems in youth with epilepsy. This screening enhanced the capacity of PCP’s, pediatric neurologists, pediatric epileptologists to detect, refer, and/or treat mental health problems in youth with epilepsy in a timely fashion.  2) To describe an effective triage network to improve access to mental health care for youth with epilepsy.

    Methods: The presenter will discuss the impact of increased screening for mental health in youth with epilepsy. A description of the mental health screening in the outpatient pediatric epilepsy clinic in the last 2 years will be discussed. 2200 patients participated in the screening using several questionnaires that evaluated seizure severity, quality of life, depression, and other psychiatric comorbidities. This screening serves as a platform for triage of the outpatient psychiatric consults during the pediatric epilepsy clinic. 720 patients already have had their second screening after the first 6 months. Two hundred patients underwent psychiatric evaluation by Dr. Falcone in the last 2 years of the grant. 25 patients with epilepsy were identified at risk of committing suicide in the last year and sent to the emergency room, 10 of those patients were admitted to the hospital

    Results: We analyzed scores from the Impact of Childhood Neurologic Disease Scale (ICNDS), Liverpool Seizure Severity Scale, and patient-reported hours of activity and number of friends using mixed models regression methods. Pairwise comparisons of the least square mean differences between QOL ratings were made using the Tukey-Kramer adjustment for multiple means comparisons. To compare differences between individual ICNDS subscales within a QOL rating, a Bland-Altman test of agreement was used. The impact of inattention, neurological/physical limitations, ability to think and epilepsy each significantly associated with reduced QOL ratings for children with epilepsy at an adjusted p-value <0.05. Bland-Altman analysis of the differences in ICNDS subscores for Attentiveness, Other Neurological Limitations, and Ability to Think against the ICNDS score for Epilepsy indicated a significant bias between the ICNDS scores of Attentiveness and Other Neurological Limitations when contrasted with the ICNDS score for Epilepsy. Increasing number of friends (p<0.0005) and hours of activity were positively associated with quality of life ratings (p<0.005). Also during results from initial screening from

    Conclusions: Psychosocial factors such as emotional symptoms and the ability to focus attention are significantly associated with reduced quality of life. Children with epilepsy have been shown to be at increased risk for ADHD, mood and behavioral problems. It is evident from this study that illness-associated symptoms of seizure frequency and severity are not the only symptoms associated with decreased quality of life.

    Objectives:

    1. Recognize an effective alternative for early screening of mental health symptoms in an outpatient sub-specialty clinic.
    2. Recognize the importance of early intervention in the treatment of psychiatric comorbidities in youth with epilepsy.
    3. Recognize the importance of screening as a resource for triage in a sub-specialty clinic as a tool for effective coordinated care in patients with epilepsy.

    Relevance:
    Mental health screening is a useful tool that could be implemented in any subspecialty clinic and can improve care coordination and delivery for medical patients with psychiatric comorbidities.

     
  12. Assessment of Psychiatric Morbidity and General Health in a Civilian Population Before and After a War in Lebanon
    Presenting Author:  Laila Farhood

    Assessments of the prevalence and predictors of psychiatric disorders in a general population from South Lebanon conducted in 2007 (n=991), one year after the July 2006 war, and in 2005 (n=632), one year pre-war, yielded high rates of psychiatric morbidity. This study utilizes a secondary analysis of both time periods to assess changes, if any, in PTSD, depression, and general health (GHQ) via scores from the Beck Depression Inventory, Harvard Trauma Questionnaire and General Health Questionnaire, respectively.

    The sample used in the secondary analysis consisted of 681 civilians initially chosen using a cross sectional design through random sampling from the same 6 villages in both 2005 and 2007. Findings revealed a drop in PTSD symptoms in the 2007 sample at a rate of 17.9% from 24.1% in 2005. There was no significant change in depression except in the 60 and above age group. A drop in GHQ-28 scores in 2007 was also observed (4.2 in 2007 from 6.7 in 2005, p value=<.001). Findings revealed the strong protective role of social support and community resilience in mental health outcomes following traumatic war events. Intervention studies incorporating both psychoeducation and psychosocial approaches are crucial for recovery.

    Objectives:

    1. Understand the importance of the impact of war on the civilian population: PTSD, Depression and general health.
    2. Apply findings of this study in helping communities traumatized by war and other disasters.
    3. Comprehend the role of social support and community resilience in mental health outcomes.

    Relevance:
    This study helps in predicting psychiatric disorders following a traumatic experience and provides information for intervention studies incorporating both psychoeducation and psychosocial approaches which are crucial for recovery.

     
  13. [T] Health Promotion and Risk Behaviors in Bipolar Patients: Perception of Effects on Bipolar Illness
    Presenting Author:  Patrick Hou
    Co-Authors:  Anna Kreiter, Nancy Maruyama

    Introduction: Bipolar disorder (BD) patients have high rates of medical illness that may be modifiable by health behaviors. Little is known about health screening and promotion behaviors (exercise, diet, etc.) in individuals with BD. High functioning BD patients report using behaviors that ameliorate medical illness (exercise, diet) to manage bipolar illness. We examine health behaviors patients with severe illness.

    Methods: Thirty-two participants, aged 44.8 years (12.4), completed self-report measures identifying medical screening behaviors (physical exam, cholesterol screening, etc.), health promotion behaviors, and their perception of these behaviors on mood and course of bipolar illness.

    Results: Of all subjects, 71.9% reported 5 to >20 depressive episodes, 59.5% with 5 to >20 manic episodes. In the past year 77% had a physical exam and 65.6% had cholesterol screening. Since diagnosis, 100% of smokers had tried to quit. 87.5% (n = 28) tried to sleep regularly and relax, 81.3% (n = 26) to improve diet, 75% (n= 24) to exercise more, and 65.6% (n = 21) to lose weight. 90.6% felt some changes could influence mood, and 71.9% felt they could influence the course of illness.

    Conclusions: A large percentage of our sample report medical screening behaviors. Similar to high-functioning patients, those with severe BD seem to be aware of the value of improving health behaviors. However, smoking data suggests they are not particularly successful in health behavior change and may face particular barriers to change. In addition to diet and exercise, behaviors such as sleep, relaxation and socializing were reported to potentially influence mood and course of BP illness. Patients' perceptions of the psychiatric effects of health behaviors can inform interventions to motivate behavior change.

    References:

    1. Murray G, Suto M, Hole R, Hale S, Amari E, Michalak EE: Self-management strategies used by ‘high functioning’ individuals with bipolar disorder: from research to clinical practice. Clinical Psychology and Psychotherapy 2011; 18:95-109.

    2. Goodrich DE, Lai Z, Lasky E, Burghardt AR, Kilbourne AM: Access to weight loss counseling services among patients with bipolar disorder. Journal of Affective Disorders 2010; 126:75-79.

    3. Jacka FN, Pasco JA, Mykletun A, Williams LJ, Nicholson GC, Kotowicz MA, Berk M: Diet quality in bipolar disorder in a population-based sample of women. Journal of Affective Disorders 2011; 129:332-337.

    4. Ramasubbu R, Beaulieu S, Taylor VH, Schaffer A, McIntyre RS: The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and comorbid medical conditions: diagnostic, assessment, and treatment principles. Annals of Clinical Psychiatry 2012; 24:82-90.

    Objectives:

    1. Understand that bipolar disorder patients have high rates of medical illness that are modifiable by health behaviors.
    2. Recognize that bipolar patients feel that in addition to diet and exercise, behaviors such as sleep, relaxation and socializing may influence mood and course of BD illness.
    3. Recognize that patients’ perceptions of the psychiatric effects of health behaviors can guide interventions to motivate behavior change.

    Relevance:
    Severely ill bipolar patients report an understanding of the beneficial effects of improving health behaviors on mood and course of bipolar illness, but face barriers to change. Patient perceptions can inform behavioral interventions.

     
  14. [T] Adherence to Treatment Advice by Consultees: Direct Communication as a Factor
    Presenting Author:  Hussam Jefee Bahloul
    Co-Author:  Abishek Rizal

    Background: Multiple factors that can affect adherence to treatment advice were identified in other studies. No findings pertaining to the level of communication as one of these factors were reported.

    Aims: To improve adherence to psychiatric treatment advice by consultees at Parkland Memorial Hospital.

    Methods: In phase one, we aimed at identifying the causes of poor adherence. In phase two, we implemented an intervention and measured its effect. Only cases of low acuity were included. Cases of high acuity (i.e., suicidality, agitation) were excluded from phase one given the nature and the urgency of these cases. During phase one, psychopharmacological treatment recommendations were provided in the electronic medical records (EMR) without any direct communication with the consultee. Rates of adherence to psychopharmacological recommendations by consultees were calculated per each individual recommendation (not per case) after 17-24 hours. In cases of non-adherence, the psychiatry consultant contacted the consultees and inquired about the reason. Based on the findings of this phase an intervention was applied in phase two.

    Results: In phase one (n=27), rate of adherence was 55.6%. In 83.3% of the non-adherent cases, the reason provided was “recommendations were not communicated directly to consultee.” There was no difference in adherence when comparing internal medicine to surgery consultees (p = 0.6). However, there was an overall significantly better adherence to recommendations concerning psychiatric conditions (e.g., psychosis, depression, etc) vs. medical conditions (e.g., delirium, dementia, etc) (p = 0.01). In phase two (n=20), after implementing an intervention of directly communicating the recommendations via phone call to consultees, rate of adherence increased to 100%. This was a statistically significant difference using a Z-test (proportions, 2-tailed) (p<.001).

    Limitations: Low sample size and lack of randomization has effects on the validity and generalizability of the outcomes. The time frame used when assessing adherence was short. We looked in this study at only one kind of treatment advice (psychopharmacological) ignoring the other kinds. Psychiatric consultation cases usually result in multiple recommendations, but in this study we looked at adherence to individual recommendations ignoring the outcome of other recommendations in the same case.

    Conclusions: In our sample, direct communication of psychopharmacological recommendations to the consultee was found to be a factor in adherence to treatment advice. Providing direct communication for each and every psychiatric recommendation can improve adherence to treatment advice. The use of EMR as the main level of communication has reduced adherence rates in our sample. More research and larger studies are needed.

    Reference:

    1. Leentjens AF, Boenink AD, van der Feltz-Cornelis CM: Can we increase adherence to treatment recommendations of the consultation psychiatrist working in a general hospital? A systematic review. J Psychosom Res 2010; 68(3):303-9.

    Objectives:

    1. Apply the findings on practice of consult psychiatry by implementing direct communication with all consultees when delivering treatment advice so to improve adherence.
    2. Help the learner understand that the use of electronic medical records as an only means of communicating treatment advice may reduce adherence.
    3. Encourage learners to create and duplicate similar projects on larger scales in different hospital settings.

    Relevance:
    It addresses adherence to treatment advice in psychiatric consultations, and provides information to improve adherence. This topic is highly relevant to the field of psychosomatic medicine and consult liaison psychiatry.

     
  15. [T] When Patients Ask to Leave AMA: Misuse of Psychiatric Civil Commitment in General Hospitals
    Presenting Author:  Tiwalola Kolawole
    Co-Author:  Mallika Lavakumar

    Purpose: Discharges against medical advice (AMA) occur at a rate of 2.5% [1] and are associated with poor outcomes such as increased mortality rates [1]. When patients are found to lack the mental capacity to make the decision to leave AMA psychiatric civil commitment papers to detain patients for medical treatment are sometimes used erroneously [2,3]. Our purpose is to highlight the sanctity of psychiatric civil commitment, explore reasons for its violation in order to detain patients for medical treatment in medical settings, and to describe measures underway at our institution to address this problem.

    Method: Case Report

    Results: We report a case of a 72 year old woman with CAD who was in cardiac arrest when she arrived in the emergency department of a large county hospital affiliated with an academic medical center in the midwestern United States. She was successfully resuscitated and found to have a STEMI. While awaiting a cardiac catheterization she asked to leave AMA and was found to lack capacity to make this decision. Psychiatric civil commitment documents were completed to keep the patient from leaving AMA. This scenario represents a frequent occurrence at our institution. We are addressing this problem by a number of means:

    1. A policy is currently under development by a multidisciplinary committee involving representatives from psychiatry, nursing, security and legal counsel clearly articulating that when a patient lacks the capacity to leave AMA, rather than use civil commitment an assessment that the patient lacks the capacity to leave AMA is documented in the chart

    2. An electronic medical record note template has been developed to guide physicians in doing capacity evaluations and to ensure adequate documentation

    3. Peer to peer education is currently underway for attending physicians, house staff nurses and security officers.

    Data collection for effects of this intervention are ongoing but preliminary results indicate a decrease in use of psychiatric civil commitment.

    Conclusions: Psychiatrists who practice in medical settings have a vital role in advocating for appropriate use of psychiatric civil commitment and can develop institutional measures to achieve this.

    References:

    1. Southern WN, Nahvi S, Arnsten JH: Increased risk of mortality and readmission among patients discharged against medical advice. American Journal of Medicine 2012; 125:594-602.

    2. Byatt N, Pinals D, Arikan R: Involuntary hospitalization of medical patients who lack decisional capacity: an unresolved issue. Psychosomatics 2006; 47(5):443-8.

    3. Mossman, D: Psychiatric holds for non-psychiatric patients. Current Psychiatry 2013; 12(3):34-37.

    4. Appelbaum PS: Clinical practice. Assessment of patients' competence to consent to treatment. New England Journal of Medicine 2007; 357(18):1834-40.

    Objectives:

    1. Learn how to perform an evaluation to assess whether a patient has the capacity to leave AMA
    2. Understand that civil committment is not indicated to detain patients for medical treatment.
    3. Become aware of methods that can be used to address this problem.

    Relevance:
    This presentation is relevant to all those who practice psychiatry in medical settings.

     
  16. [T] Health Screening Rates in Bipolar Patients Compared to National Norms
    Presenting Author:  Anna Kreiter
    Co-Authors:  Stephanie Cheung, Nancy Maruyama

    Introduction: Bipolar disorder (BD) patients have higher rates of heart disease, stroke, diabetes, pulmonary disease, and obesity when compared with national cohorts and other samples. BD is associated with greater fatality and earlier death from cancer and medical illness, making health screening behaviors imperative in this population. We compared health screening behavior in a sample of severely ill bipolar patients to national screening rates for non-psychiatric samples.

    Methods: Thirty-two men and women with BD diagnosis completed self-report questionnaires on demographics, illness severity and health screening behaviors.

    Results: 19 women and 13 men, mean age 44.8 years (12.4) were largely severely ill. 25% reported a history of 5-10 depressive episodes, 46.9% reported > 19 depressive episodes. 34.4% reported 5-10 manic episodes and 25.1% >19 manic episodes. BD patients had a higher rate of physical exams at 75 visits or more per 100 persons vs. the national average of 45 visits per 100 persons (2009). BD patients were more likely to get a flu shot than national averages, at 43.8% vs. 35.8% (2010). Rates of colorectal screening, including stool for occult blood or colonoscopy, were slightly lower for BD patients, at 54% vs. 59% nationally (2010). BD patients were less likely to screen for cervical and breast cancers with PAP smears (63% vs. 73.2% nationally, 2011) and mammogram (66.6% vs. 75.4% nationally, and 77.6% in NY State, 2010). Cholesterol screening was lower among BD patients, at 65.6 % vs. 76% nationally and 80.8% in NY State (2009).

    Conclusions: Results are consistent with previous studies that find BD patients have more contact with primary medical doctor (PMD) than controls. Our data show BD patients screen for cancers and cardiovascular risk factors at rates lower than national averages, although the literature is mixed. It is clear in the literature that BD patients receive fewer treatments for medical issues and die earlier from them. Psychiatrists and PMDs should collaborate to take advantage of BD patients’ frequent PMD contact to increase screening. There should be particular focus on helping BD patients with positive screens to adhere to follow up medical appointments and treatments. Interventions to address the barriers BD patients face in the process of screening and treatments may decrease disproportionate fatality rates in the BD population.

    References:

    1. Kisely S, Crowe E, Lawrence D: Cancer-related mortality in people with mental illness. JAMA Psychiatry 2013; 70(2):209-217.

    2. McGinty EE, Zhang Y, Guallar E, et al: Cancer incidence in a sample of Maryland residents with serious mental illness. Psychiatric Servicea 2012; 63:714-717.

    3. Hippisley-Cox J, Vinogradova Y, Coupland C, et al: Risk of malignancy in patients with schizophrenia or bipolar disorder. Archives of General Psychiatry 2010; 64:1368–1376.

    Objectives:

    1. Understand bipolar patients’ increased risk of morbidity and mortality from medical diseases and their need for health screening.
    2. Recognize the disparity between rates of bipolar patients’ visits to primary medical doctors and rates of screening and treatments for cancers and heart disease.
    3. Recognize the need for joint interventions and support by a psychiatrist/primary medical doctor team to increase adherence to follow-up medical appointments and treatments.

    Relevance:
    High rate of contact with PMD does not correspond to improved screening for medical illnesses in BD populations. Psychiatrists and physicians must collaborate to meet challenges of screening and follow-up.

     
  17. [T] Five-year Evaluation of Consultation-Liaison Psychiatry Referrals in a Tertiary Medical Center
    Presenting Author:  Jeanne Lackamp
    Co-Author:  Pu Cheng

    Background: In the era of global mental health challenges, psychiatric disorders take a heavy toll both independently and in combination with medical conditions. Psychosomatic medicine (consultation–liaison psychiatry) is well-positioned on the frontline of medicine, by contributing expertise in integrating and exploring the interface of psychiatry and medicine. However, few studies evaluate the evolution of this subspecialty in a large scale over time.

    Methods: Collection and analysis of psychiatric consultations within a U.S. metropolitan tertiary hospital over five consecutive years (2007-2011). Multiple psychiatric variables were reviewed, including patient demographic data, reason for referral, psychiatric diagnosis, and recommended management. At this time, only 2007 preliminary data is available for presentation, as analysis of the other years is still ongoing.

    Results: There were total 7,063 psychiatric consultation cases from 2007-2011 (1,134 cases from 2007; 43% males and 57% females, with 28% over 65 yo). Through the five years, annual consultation rate increased from 3.4% to 6.4% of total adult inpatient medical/surgical hospitalizations. This is much higher than 0.9%-1.7% reported in other literature. Depression remains the most common reason for referral, which is consistent with other published studies. Interestingly, substance use issues and confusion are the next two most common consultation questions in our study, while anxiety followed depression in other studies. Among our consultation recommendations, non-pharmacologic approaches are the most common including music/chaplain service, support, capacity and expert evaluation, etc; while antipsychotic and antidepressant medication recommendations share the second position.

    Conclusions: Although the project is still in progress, based on the 2007 data there are slightly more consultations for female than male patients; fairly large percentage of elderly (>65 yo) patients; and depression is our top consultation reason, which is consistent with other studies. Interestingly, our consultation rate is much higher than reported in other studies, and it has been consistently rising in the five years analyzed. Consultation patterns and shifts will be revealed once the entire study is finished (more data will be added to the study after the submission of this abstract). Determining patterns of psychiatric consultations will inform future directions for service provision and educational opportunities.

    Objectives:

    1. To demonstrate the unique pattern, as well as pattern shifts, in a 5-year period of consultation-liaison (C-L) psychiatry in a metropolitan general hospital.
    2. To compare our data to other reported C-L psychiatry patterns, and to identify differences and discuss possible reasons for these differences.
    3. To determine patterns of psychiatric consultations, thus informing future directions for service provision and educational opportunities.

    Relevance:
    This will bring us a clearer view of current consultation-liaison (C-L) psychiatry trends, and will give perspective for future development of this important subspecialty of psychiatry.

     
  18. [T] Characteristics and Outcomes of Suicidal Patients Referred to a Psychosomatic Medicine Consultation Service
    Presenting Author:  Vicente Liz
    Co-Authors:  Maria Perez Coste, Victoria Paz, Hamad Mohsin, Dora Duque, Ali Khadivi

    Introduction: In 2007 suicide was the 4th leading cause of death in the U.S. for adults 18 - 65, surpassing diabetes, stroke, and homicide.¹ (CDC’s National Vital Statistics System)

    In 2008, 3.7 % of adults 18 and older in the US had thought about suicide, 1.0 % had made plans to commit suicide, and 0.5 % had attempted suicide.² (SAMHSA), 2008 National Survey on Drug Use and Health (NSDUH)

    In 2007, 395,320 people were treated in emergency departments for self-inflicted injuries and 165,997 people were hospitalized due to self-inflicted injury.³ (CDC’s web-based Injury Statistics Query and Reporting System)

    Despite the vast literature on suicide, there have been few studies examining the characteristics of suicidal patients admitted to a medical service that had received a psychiatric consulation. Some of this research has been conducted in Europe with almost no studies being conducted in the U.S. Understanding clinical characterisitics, demograhics, and treatment outcomes of suicidal patients admitted to medical units can potentially further improve suicide risk assessment and treatment outcomes.

    Objective: To assess the clinical, sociodemographics, and treatment outcomes of suicidal patients admitted to a major inner city medical center and referred to a psychiatric consulation service.

    Method: The study is IRB approved and designed as a retrospective chart review of adult patients (n=140) admitted to a major medical center in New York, in the period of September 2011-May 2012 consulted by the psychosomatic medicine service for suicidality. The patients are selected from a log of all psychosomaitc consults ordered.

    Results: The mean age was 43.4 (SD=14.8) with 56.4% being male and 43.6% female. The majority were Hispanic, 61.4% with 82% of sample being unempolyed. The vast majority was referred by EMS (67.1%). The most common presentaton was suicidal ideation (58.6%) follwed by suicidal attempt (33.6%). Majority of the sample (75%) was not being followed by a mental health team. Overdose was the most common form of attempt (76%) and nearly 59% had engaged in a near lethal attempt. Less than half attempters had previous suicidal acts. Patients with attempts were more likely to be male (55.3%). At time of consult 85% were on constant observation. Following the consultation, 67% of constants were discontinued, 35% were admitted to psychiatry, 22% referred to additcion services, 29.3% to outpatient mental health services and 12% to medical services.

    Conclusions: Suicidal patients referred to the PM consulation service have significant risk factors and are not likely to be recieving any mental health treatment at the time of consultation. The PM consultation helps to integrate the suicidal patient with mental health services and reduces the potential cost of constant observations.

    Objectives:

    1. To highlight the frequency of suicidal assessments as one of the major consulting issues in inner city hospitals.
    2. To better understand the clinical characterisitics, demograhics, and treatment outcomes of suicidal patients admitted to medical units.
    3. To potentially further improve suicide risk assessment and treatment outcomes.

    Relevance:
    Few studies examine the characteristics of suicidal patients admitted to a medical service receiving a psychiatric consultation. Most research has been conducted in Europe with few studies in the U.S.

     
  19. [T] Do Non-psychiatric Care Providers Also Have the “Duty to Protect”?
    Presenting Author:  Rachna Raisinghani
    Co-Author:  James Levenson

    Objectives: A vast majority of patients with mental illness are seen exclusively in the primary care setting. A non-psychiatric provider may learn of a threat to harm a known person or persons in the course of treating such an individual. The objective of this project is to explore how commonly non-psychiatric physicians encounter such patients and discuss the "Duty to Protect" as applicable in such a situation.

    Methods: We conducted an online survey of physicians from family medicine, general internal medicine and subspecialties of internal medicine at Virginia Commonwealth University regarding their experience with patients who expressed threat of harm towards a known person or person, and their response to it. We also reviewed the available literature on PubMed using keywords Duty to Protect/Duty to Warn, Tarasoff + various terms for non-psychiatric providers.

    Results: Of the 31 respondents, over 50% had treated a patient who went on to express a threat to harm a known person(s). Of those, the majority asked for a psychiatric consultation. A third sent the patient to the ER or called the police. Only one provider called the potential victim. Almost all respondents reported some discomfort in handling the situation.

    Conclusions: Whereas the statutes inspired by Tarasoff are applicable to psychiatrists in many states, the law does not state clearly whether a primary care provider treating a patient for a psychiatric condition would assume the same medico-legal responsibility. In settings without access to a psychiatrist, the onus on the primary care provider is even greater. Thus, it is important for all providers to be familiar with laws pertaining to the Duty to Protect in the state where they practice, and for educators to include this topic in the instruction of medical students and residency trainees.

    Objectives:

    1. Appreciate the historical context of the Duty to Protect, and investigate its application in their state of practice.
    2. Analyze the question posed in the paper and be able to discuss the nuances.
    3. Apply the information from the paper for liaison with non-psychiatric medical professionals when the latter are faced with a homicidal patient.

    Relevance:
    Non-psychiatric providers managing mental illness who see patients with intent to harm others should know about relevant medico-legal responsibilities when faced with such patients.

     
  20. A Decade of Early Intervention for Psychiatric Patients in Hospital Emergency Rooms by a Behavioral Health Intake Team
    Presenting Author:  Vani Ray
    Co-Authors:  Joy Mead-Meucci, Mary Pelner, Maharaj Singh

    Purpose: To evaluate the role of a Behavioral Health Intake Team (BHIT) in six emergency rooms in an integrated health care system in Wisconsin.

    Methods: Aurora Healthcare is the largest provider of health care and behavioral health services in the state of Wisconsin. Six hospitals in Milwaukee and surrounding areas of Wisconsin were selected to integrate this novel behavioral health model of early access to care. Each BHIT, composed of master's level psychotherapists or nurses, assess patients with behavioral health needs for level of care determination and triage, with close collaboration by an on-call psychiatrist. The team in addition manages requests for psychiatric consults to acute care units.

    Data was collected for patients assessed every year since 2001 and for patients evaluated by the psychiatric consultation liaison team since 2008. A 10-question survey was sent to emergency room staff to evaluate the role and the effectiveness of the BHIT.

    Results: The BHIT in 3 emergency rooms evaluated 848 patients in 2001. By 2012, 3 additional emergency room sites were added and utilization totaled 42, 929 patient evaluations in 11 years. Simultaneously the psychiatric consultation liaison service to acute care settings, expanded from 1 hospital to 7 hospitals. Consult requests received by the BHIT totaled 22,197 in the last 5 years.

    According to survey results (N=90) more than 90% of respondents rated the availability and effectiveness of the BHIT from very good to excellent on a five point scale; showed the presence of BHIT reduced the length of the stay in the ER; provided expertise and resources to the emergency rooms and medical surgical teams; assisted in the reduction of inappropriate admissions to medical surgical units; increased timely admissions to inpatient psychiatric units; and established behavioral health care plans to reduce recidivism in hospital admissions.

    Conclusions: The availability of a dedicated Behavioral Health Intake Team proved to be an effective strategy to improve the timely access of care to patients with behavioral health needs in both emergency rooms and acute care units. Further exploration of available data and ongoing research will provide evidence of improved patient care and cost savings to the health care system.

    References:

    1. Mark TL, Vandivort-Warren R, Owens PL, Buck JA, Levit KR, Coffey RM, Stocks C: Psychiatric discharges in community hospitals with and without psychiatric units: how many and for whom? Psychiatr Serv 2010; 61(6):562-8.

    2. Stefan S: Emergency department treatment of the psychiatric patient: policy issues and legal requirements. New York: Oxford University Press, 2006.

    Objectives:

    1. To familiarize the physician learner with a novel approach to improve early access to behavioral health care.
    2. To analyze how the presence of a Behavioral Health Intake Team in a hospital emergency room compliments the functioning of the csultation-liaison psychiatry service in an acute care setting.
    3. To weigh the relative benefits and costs of pursuing this novel intervention in emergency rooms and acute care settings.

    Relevance:
    In the changing face of health care, collaborative interventions are essential to compassionate and dynamic care. Our integrated team approach in emergency rooms and acute care settings provides a perfect example.

     
  21. [T] The Fallacy of “Medical Clearance”
    Presenting Author:  Carolina I. Retamero
    Co-Authors:  Yen-Hua Yu, John J. Kelly

    Background: The term “medical clearance” is used frequently by emergency medicine physicians before transferring a patient to a psychiatric facility, and it generally means that the patient’s psychiatric symptoms are not of organic etiology, that the patient has no acute medical illness, and that the patient warrants no further medical work up. Such “medical clearance” may be compromised as physicians are not immune to the stigma that surrounds psychiatric patients which results in less likelihood of performing further testing to rule out medical comorbidities.

    Objective/Purpose: We present two challenging cases of elderly patients that were medically cleared by the emergency department, transferred to the psychiatric unit, and within 24 hours, transferred to the medical unit. The first patient had a hemoglobin of 6gr/dl and the second patient had suspected foot gangrene.

    Methods: We reviewed the charts of the two cases in our electronic medical records. PubMed literature search was performed using words: “medical clearance”, “physician bias in psychiatric patients”, “schizophrenia pain”.

    Discussion/Results: Retrospective studies of medical clearance in patients with psychiatric complaints conclude no testing is required in patients with known psychiatric illness, no medical complaints, and with normal physical exam and vital signs. Studies performed in both inpatient psychiatric unit and the emergency department concluded that universal testing is of low yield with the above mentioned parameters. However, the evaluation of our two asymptomatic patients was incomplete secondary to the patients’ refusal to provide history and undress, characteristics that are common in psychiatric patients.

    Certain groups of patients have been identified as being at high risk for medical illness: elderly, history of substance abuse, without psychiatric history, with pre-existing medical disorders, and from lower socio-economic level. To make diagnosing more complex, patients with schizophrenia have a higher threshold of pain and may not present with a worrisome history or physical exam.

    Our cases highlight the importance of obtaining a detailed history and physical exam. Mentally ill patients may play an unintentional role in their medical clearance and physicians should carry a high index of suspicion in these patients. Medical clearance seems to imply that many differential diagnoses were considered and ruled out, which may be inaccurate in some cases and detailed communication between the transfer and accepting teams should be warranted.

    References:

    1. American College of Emergency Physicians: Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med 2006; 47:79-99.

    2. Janiak BD, Atteberry S: Medical clearance of the psychiatric patient in the emergency department. J Emerg Med 2012; 43:866-870.

    3. Korn CS, Currier GW, Henderson SO: “Medical Clearance” of psychiatric patients without medical complaints in the emergency department. J Emerg Med 2000; 18:173-178.

    Objectives:

    1. To demonstrate the fallacy with using the term "medical clearance" in psychiatric patients of limited history or physical exam.
    2. To identify the group of psychiatric patients that are more likely to have acute medical conditions.
    3. To determine which psychiatric patients who present for medical clearance warrant further medical workup.

    Relevance:
    Psychiatrists and emergency physicians often transfer patients to and from the units for medical and mental evaluation. Medical conditions may be missed despite medical clearance.

     
  22. Identifying the Costs and Treatment Patterns of Depression with Fatigue and Other Common Symptoms
    Presenting Author:  Rebecca Robinson
    Co-Authors:  Judith Stephenson, Ellen Dennehy, Douglas Faries, Michael Grabner, Swetha Rao Palli, Ralph Swindle

    Purpose: This study assessed the impact of residual and/or associated symptoms of depression on healthcare costs. Fatigue, a common and disabling symptom of depression, was further examined to determine its impact on clinical measures.

    Methods: Adults (ages 18 to 64) with >2 medical claims with ICD-9-CM depression diagnosis code(s) between 6/1/2009 through 5/31/2010 from the HealthCore Integrated Research DatabaseSM were invited to participate in this retrospective/prospective fixed-cohort repeated-measures study. Participants completed initial (baseline) and 6-month surveys assessing depression (Quick Inventory of Depressive Symptomatology, QIDS-SR16), fatigue (Fatigue Associated with Depression, FAsD), anxiety (Generalized Anxiety Disorder, GAD-7), insomnia (Athens Insomnia Scale, AIS), pain (Brief Pain Inventory, BPI), and general health (General Health Questionnaire, GHQ-12). Baseline survey data were linked to 24 months of claims data (+12 months of baseline survey). Mean total costs were compared using non-parametric bootstrapping methods between patients with and without clinically significant symptom levels based on standard cutpoints for each symptom scale. Additional analyses for fatigue cohorts were conducted to adjust for initial differences in demographics and health status using propensity score (PS) strata bootstrapping method.

    Results: Study patients (N=1,985) were primarily female (77.3%), white (91.1%), with a mean (SD) age of 46.6 (11.6). Significant levels of pain, sleep disruption, and anxiety were present in 36.1%, 61.5%, and 40.6% of patients, respectively. Higher total healthcare costs were observed in patients with each symptom, compared to those without (all p<0.05). Thirty-three percent (n=653) of patients had fatigue and subsequently had mean 12-month total healthcare costs $4,491 higher than patients without fatigue ($14,462 vs. $9,971, p<0.001). Patients with fatigue reported significantly (p<0.05) greater presence and severity (mean (SD) score) of depression symptoms (95.1% vs. 59.5%; QIDS-SR16 12.6 (4.5) vs. 7.1 (4)), pain (57.1% vs. 25.7%; BPI 3.8 (2.6) vs. 2 (2.2)), sleep disruption (88.8% vs.48.1%; AIS 10.7 (4.5) vs. 5.7 (3.8)) and anxiety (68.3% vs. 26.9%; GAD-7 10.6 (5.4) vs. 5.5 (4.6)). Patients with fatigue were more likely to have hospital (12.6% vs. 10.1%) and ER (22.8% vs. 14.8%) visits and to be in poorer health (GHQ-12: 18.7 (6.5) vs. 12.3 (5.4)). PS-adjusted analyses indicated that patients with fatigue continued to have significantly higher costs than patients with no fatigue ($12,548 vs. 10,708, p<0.0001). Findings were nonsignificant when restricting the sample to those with QIDS-SR16 scores >5.

    Conclusions: Patients with depression experience significant symptoms, which add to the economic burden of illness. Study patients with fatigue also reported greater presence and severity of depression symptoms as well as multiple other disease symptoms. While this study does not distinguish whether the symptom is a residual symptom of depression or a comorbid illness, it does emphasize the importance of treating patients to full resolution of all symptoms.

    Objectives:

    1. To understand the health care costs and utilization for patients with depression and prominent residual or associated symptoms.
    2. To identify patient characteristics associated with the presence and severity of depression.
    3. To understand the role of fatigue with depression on clinical and economic outcomes.

    Relevance:
    This study highlights the role of patient heterogeneity in depression including the relevance of symptoms such as fatigue, insomnia, pain, and anxiety and their impact on clinical and economic outcomes.

     
  23. Proposal for a Psychosomatic Database in the EPIC EMR
    Presenting Author:  Akhil Shenoy
    Co-Authors:  Kim Klipstein, Carrie Ernst, James Strain

    Background: The implementation of electronic medical records (EMRs) is one of the primary goals of current health care reform. The utility of a psychiatric database can potentially help patient outcomes, enhance teaching, and reduce costs. One such database, the Micro-Cares Clinical Information System for Consultation-Liaison Psychiatry (CISCL), is a proven stand alone patient management application. Today, the EPIC EMR is the largest and fastest growing EMR in the United States though it currently has no associated psychiatric database. We propose a new psychosomatic database to incorporate into EPIC that would further the development of psychosomatic work in the following 4 areas: Clinical, Administrative, Research and Education.

    Methods: We translated the patient variables in CISCL to work within the EPIC structure and identified stakeholders in the design of the database. Those groups that stand to benefit from such a program include not only C-L psychiatrists but also consultees, other consulting medical teams, psychiatric trainees, billing staff, and EPIC programmers/consultants. We conducted focus groups and a survey to help in the formative evaluation of the database.

    Results: After 6 months of use, we have positive feedback on the implementation of the EPIC database. We achieved thorough data collection to aid thoughtful assessment, recommendations, and communication for overall improved patient care. We were able to use the EPIC report writing feature to produce weekly and monthly reviews of physician caseloads to help give constructive feedback to trainees

    Discussion: This EPIC based database can potentially serve and promote all the goals of a busy C-L division practice. We found several advantages to using an existing EMR as a data collection tool. The infrastructure of the EMR is already collecting data on each admission to help save time for the individual consultant. The hospital would not need to financially support an additional data collection tool for a C-L service. EPIC being a widely used EMR may also help standardize psychiatric consultation data management. Future endeavors include generating patient de-identified data for for quality improvement projects and research.

    References:

    1. Hammer J, Strain JJ, Friedberg A, Fulop G: Operationalizing a bedside pen entry notebook clinical database system in consultation-liaison psychiatry. Gen Hosp Psychiatry 1995; 17:165-172.

    2. Chiu NM, Strain JJ, Sun TF, Strain JJ, Lee Y, Chong MY, Wen JK: Development of a Taiwanese computerized database for psychiatric consultation in a general hospital. Gen Hosp Psychiatry 2005; 27(4):292-7.

    3. MoukheiberZ: "Epic Systems' Tough Billionaire." Forbes Magazine April 2012. Forbes Web. 7 May 2012.

    4. Bajgier J, Bender J, Ries R: Use of templates for clinical documentation in psychiatric evaluations-beneficial or counterproductive for residents in training? Int J Psychiatry Med 2012; 43(1):99-103.

    Objectives:

    1. Review the goals and benefits of an electronic psychosomatic database.
    2. Learn a process of implementing these goals in a modern EMR system such as EPIC.
    3. Identify which reports may be helpful to one's own service to further these goals.

    Relevance:
    The EMR is in widespread use and this process of creating a database should quickly allow other C-L divisions to promote their goals in clinical care, administration, research, and education.

     
  24. [T] Did You Even Read My note?: Inaccurate Documentation of Psychiatric Consultations by Consultees May Lead to Medical Errors
    Presenting Author:  David Sheski
    Co-Author:  Saba Syed

    Purpose: The movement toward integrative care is occurring in an era in which increasing use of electronic medical record (EMR), duty hour restrictions, and frequent patient hand-offs have made accurate communication via the medical record critically important to patient care, and many issues have begun to arise in regard to both ethics and quality relating to the use of EMR [1]. Not all of the recommendations and diagnoses of psychiatric consultants are accurately represented in the medical record or implemented by consultees. Calling the primary service and asking the question "did you even READ my note?" has likely crossed the mind of many consultants at one time or another. In a study done prior to the use of EMR, the concordance rate for psychotropic drug recommendations was 63% and that for accurate diagnostic representation was 43% [2]. We sought to evaluate the concordance rates with which our psychiatric consult assessments and recommendations are being documented by primary services in our hospital's newly implemented EMR system. We highlight specific examples of inaccurate documentation by consultees that have either lead to medical errors or have the potential to do so. In one example, inadequate documentation of the clinical picture lead to the discontinuation of Ativan and decompensation of a catatonic patient. In another, delirium was inaccurately documented as new onset psychosis in the discharge summary of a patient with stage IV breast cancer, which could lead to failure to recognize delirium and unnecessary anti-psychotic treatment in future hospitalizations.

    Methods: A retrospective chart review looked at 65 inpatient psychiatric consults seen over a 3 month period. We collected data on the frequency with which consulting services 1) followed psychiatric recommendations, 2) acknowledged that psychiatry had been consulted, and 3) accurately documented the assessment, diagnosis, and recommendations of the consultation in their progress notes and discharge summaries. The primary team's progress notes and orders were reviewed starting with the day of initial psychiatric consultation through to the patient's discharge summary.

    Results: Concordance with psychiatric recommendations was 83% (53/64). Services were acknowledging having consulted psychiatry at similar rates of 84% (53/63) for progress notes and 89% (56/63) for discharge summaries, but we found that accurate documentation of our assessment, diagnosis, and recommendations was much lower at 53% (32/60) for progress notes and 57% (36/63) for discharge summaries.

    Conclusions: In order to prevent medical errors and inappropriate treatment there is increased need for primary services to accurately document psychiatric assessments and diagnoses in the EMR system.

    References:

    1. Bernat JL: Ethical and quality pitfalls in electronic health records. Neurology 2013; 80:1057-1061.

    2. Popkin, et al: Consultation-Liason outcome evaluation system. Arch Gen Psychiatry 1983; 40:215-219.

    Objectives:

    1. To analyze the frequency with which psychiatric consultation recommendations are followed.
    2. To analyze the frequency with which the psychiatric assessment and diagnosis were accurately reflected in the primary team's documentation.
    3. To highlight how inaccurate documentation can lead to significant medical errors and complications.

    Relevance:
    With the movement toward integrative care it is essential for the psychosomatic medicine psychiatrist to educate consultees about the importance of accurate documentation of psychiatric assessments and recommendations.

     
  25. “It’s Good That the Group is Here” – An Evaluation of a Psychosocial Group to Support Engagement with HCV Treatment
    Presenting Author:  Sanjeev Sockalingam
    Co-Authors:  Zoe Dodd, Kate Mason, Christopher Meaney, Molyn Leszcz

    Background: Individuals with hepatitis C (HCV) often have high rates of psychiatric comorbidity and substance use, which can be significant barriers to HCV treatment. This is especially problematic given the high rates of mental health and substance use issues amongst people living with HCV. Group psychotherapy has been used widely with many populations of medically ill individuals and promises to be an ideal model to support individuals pursuing HCV therapy; however, its acceptability and effectiveness for this population have not been previously studied.

    Purpose: This study sought to describe the client characteristics and program setting of a community-based, interprofessional HCV treatment and support program in Toronto, Canada. We examined which client factors affected drop-out/attendance, and if clinical measures of group process improved over time and were related to psycho-social outcomes.

    Methods: Questionnaire data was collected at baseline and subsequent time points, over three cycles at each of the three program sites. Depression and anxiety were measured using the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) scales, respectively. We measured group process using the Empathy Scale - Patient's Version for therapeutic alliance and the TFI-Cohesiveness Scale for group cohesion. Demographics and health information was collected via chart review. Patients were coded as "group non-attenders" if they attended fewer than 12 sessions per group cycle (16-19 sessions).

    Analysis of 30+ client/demographic factors potentially influencing group non-attendance (drop out) and cumulative sessions attended were performed using logistic and linear regression (respectively). Comparison of PHQ-9 and GAD-7 scores between baseline and week 16 (in each cycle separately) was accomplished using a Wilcoxon Signed Rank test

    Results: 71% of participants were male, with an average age of 47 years. 10% were HIV co-infected. 57% of patients reported current crack use and 47% had history of psychiatric hospitalization. The average number of sessions attended per cycle was 12 (range: 0-19). The non-attendance (drop out) rate was 19%. Few consistent associations were observed between demographic variables and the likelihood of group drop-out or attendance. Few demographic variables were predictive of change in PHQ-9, GAD-7 or group process measures. Improvement in anxiety and depression tended to be associated with improved group process measures. The end of treatment cohesion score for all cycles was >53 (range: 53.08-56.87), which were considered high cohesion (defined as TFI>40 for other less marginalized group programs).

    Conclusion: Both group cohesion and attendance were higher than might be anticipated for this population. This study suggests that marginalized individuals living with HCV are able to engage and benefit from structured group therapy and that the group model is an effective method for engaging marginalized individuals in health care.

    Objectives:

    1. To list barriers to engaging marginalized individuals with comorbid substance use and hepatitis C.
    2. To understand how group psychotherapy can be an effective intervention to engage marginalized individuals in medical and psychiatric care.
    3. To identify key predictors of group psychotherapy adherence for this hepatitis C infected patient population.

    Relevance:
    Attendees will learn about an effective way to engage marginalized individuals in medical care through psycho-educational support.

     
  26. WITHDRAWN
     

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Section I:  Training and Education

  1. [T] Watch and Learn: The Use of Video Vignettes as an Assessment Tool on the Psychosomatic Service
    Presenting Author:  Marley Doyle
    Co-Authors:  Robert Lloyd, Carolyn Auffenberg, Lisa Rosenthal

    Purpose: Using video vignettes can be a useful and innovative method of objectively measuring residents' proficiency in diagnosis and treatment. Since the discontinuation of live interviews, video-recorded vignettes are now used for the ABPN board exam, and are increasingly used as an assessment tool for psychiatry residents and fellows. Video recording has traditionally been used to evaluate psychotherapy training sessions; it is now being implemented as an instructional tool to teach specific skills, though it has not been tested on psychosomatic diagnoses. In this pilot study, we set out to teach and evaluate psychiatry residents through the creation of video vignettes demonstrating common psychosomatic presentations.

    Methods: The video vignettes were created at our home institution, using evidence-based practices to guide accurate clinical cases, diagnosis and treatment. Each video was approximately thirty minutes in length and included pertinent history, physical exam findings, and lab and imaging results which allowed for complete diagnostic assessment.

    Results: After viewing the video, the resident will complete a post-test regarding the information presented in the video vignette. Results of the post-test will be used to objectively evaluate the resident's mastery of the case. There are a total of 28 residents in our suggested sample, and data will be collected to measure resident competency. Resident satisfaction surveys will also be collected to evaluate the perceived effectiveness of the intervention.

    Conclusion: Video vignettes are a useful assessment tool for common psychosomatic cases in a psychiatry residency program. Further research would include a larger sample size at different clinical sites to compare results among residency programs.

    References:

    1. Delorme R, Chaste P, Scheid I, Cortese S, Mouren MC: Using videotaped vignettes to improve the teaching quality in child and adolescent psychiatry. Med Teach 2010; 32(8):703-4.

    2. Fox G: Teaching normal development using stimulus videotapes in psychiatric education. Acad Psychiatry 2003; 27(4):283-8.

    3. Kaaya S, Goldberg D, Gask L: Management of somatic presentations of psychiatric illness in general medical settings: evaluation of a new training course for general practitioners. Med Educ 1992; 26(2):138-44.

    4. Manring J, Greenberg RP, Gregory R, Gallinger L: Learning psychotherapy in the digital age. Psychotherapy (Chic) 2011; 48(2):119-26.

    Objectives:

    1. Demonstrate how video vignettes can be used on the psychosomatic service.
    2. Evaluate core competencies of psychiatry residents using video vignettes.
    3. Discuss other ways in which viedo vignettes can be used in residency and fellowship programs.

    Relevance:
    This poster is relevant to all attendees who are involved in resident/fellow education and are seeking alternatives to teaching core competencies.

     
  2. [T] Physical Examination and Psychiatry Residents: Issues and Opportunities for Change
    Presenting Author:  Madhavi Latha Nagalla
    Co-Author:  Michelle Riba

    Purpose: 1) review the importance and value of performing a physical exam in psychiatry; 2) analyze possible reasons for the decline in practice; 3) introduce ideas and opportunities for curriculum changes in psychiatry residency and in the PSM fellowship.

    Method: We did a focused review of the literature regarding: a) the importance of physical examination by psychiatrists; b) surveys conducted to analyze attitudes and practices of psychiatrists in various settings; c) recommended changes in the psychiatric training curriculum to encourage psychiatrists to retain their physical and neurological examination skills.

    Results: We summarized the information from all reviewed articles into four headings:

    a) Why is it important to conduct physical examinations in Psychiatry?

    b) Why is it a lost art now?

    c) Our report cards discussing our skills in physical examination (1970s - date)

    d) Curriculum changes that can be introduced and evaluated for improvement in patient care and outcome.

    Conclusion: It is important for psychiatry trainees to be empowered to consistently perform complete physical examinations. Such changes may be brought about by making changes in the training curriculum, and evaluating these changes over time.

    REFERENCES:

    1. Norton J: The importance of the physical exam in a psychiatry residency program. Academic Psychiatry 2001; 25;236-237.

    2. Mc Intyre JS, Romano J: Is there a stethescope in the house and is it used? Arch Gen Psychiatry 1977; 34(10):1147-51.

    3. Krummel S, Lathol RG: What you should know about physical examinations in psychiatric patients - results of a survey.

    4. Hodgson R, Adeyemo O: Physical examinations performed by psychiatrists. International Journal of Psychiatry in Clinical Practice 2004; 8(1):57-60.

    Objectives:

    1. To understand the importance of physical exam in psychiatry.
    2. To try and understand the possible reasons why residents and fellows in psychiatry are not performing physical examinations throughout training.
    3. To look into the curriculum changes that will encourage psychiatry trainees to retain their physical and neurological examination skills.

    Relevance:
    It is important to endorse the importance of the lost art of physical examination and to encourage trainees to retain their skills by practising it regularly.

     
  3. Psychosomatic Medicine Training as a Bridge to Practice: Training and Professional Practice Patterns of Early Career Psychosomatic Medicine Specialists
    Presenting Author:  Eliza Park
    Co-Authors:  Divy Ravindranath, Patrick Aquino, Jonathan Gerkin, Sarah Francis Nemeroff, Sanjeev Sockalingam

    Purpose: Psychiatrists trained in psychosomatic medicine (PM) have specialized expertise in the diagnosis and treatment of psychiatric disorders in complex, medically ill patients. Despite the growing need for psychiatrists trained to care for this population, the number of applicants for the subspecialty has not equaled the rapid development of fellowship programs. The reasons for this discrepancy are likely varied and multifactorial, and may be found in the experience of new entrants into the subspecialty. To investigate this question, we conducted a survey of early career psychiatrists (ECPs) practicing PM to identify the personal and professional characteristics of ECP PM specialists and to examine the relevance of psychosomatic medicine training to professional practice.

    Methods: ECPs who attended the 2012 annual Academy of Psychosomatic Medicine (APM) meeting or were registered members of the APM completed a survey on training and work experiences. Decisional factors associated with pursuance of subspecialty fellowship education and professional practice patterns were identified. Descriptive statistics were used to describe the sample. Categorical demographic variables were compared between subjects pursuing a PM and not pursing a PM fellowship using chi square tests.

    Results: 102 ECPs completed the survey. Most respondents were female (57%), worked in an urban setting (79%), and were an APM member (83%). Sixty-seven (67%) of respondents completed a PM fellowship. There was no significant difference in practice setting, gender, geographic environment of practice and percent of time spent in non-PM or PM clinical activities between ECPs who completed fellowship training compared to ECPs who did not complete fellowship. Motivating factors for pursuing fellowship training were to obtain additional clinical training, to develop a special interest in PM training and to improve job candidacy. On average, most (80%) ECPs desired inpatient consultation-liaison positions and 81% looked for a job that included inpatient PM after they completed their training. 22% reported difficulty obtaining employment in PM after training.

    Conclusions: PM fellowship training remains relevant and important to ECPs in this sample. The results of this survey can be used by PM training programs to guide their development of resources and programs to address early career transition needs. Additional guidance is needed from training programs or national organizations on career development and job selection to improve ECPs ability to successfully seek PM sub-specialty work.

    Objectives:

    1. To enhance awareness of the training needs of early career psychiatrists.
    2. To examine the relevance of PM fellowship training to clinical practice.
    3. To stimulate discussion of how the APM can better serve early career psychiatrists.

    Relevance:
    Successful recruitment and training of early career psychiatrists in psychosomatic medicine is crucial for the future of the field.

     
  4. Practice and Career Choices of Female Consultation-Liaison Psychiatrists in Ohio
    Presenting Author:  Stefani Parrisbalogun
    Co-Authors:  Jeanne Lackamp, Marianne Jhee, Sarah Nagle

    Background: The practice patterns and career paths of female psychiatrists who are boarded in consultation-liaison psychiatry are not well understood. Given increased attention to integrated behavioral health care, these individuals may play an important role.

    Objective: To identify the practice patterns and career paths of female psychiatrists who are boarded in consultation-liaison psychiatry.

    Method: A survey was distributed to all female physicians identified by the American Board of Psychiatry and Neurology as boarded in consultation-liaison psychiatry in Ohio.

    Results: Pending

    Conclusion: Female consultation-liaison psychiatrists in Ohio appear to be a distinct group within general psychiatry and may serve as an important bridge in integrated behavioral health care because of their various leadership roles and diverse medical psychiatric practice patterns. Further understanding of their career development and roles nationally would be beneficial.

    References:

    1. Geppert CM, Cohen MA: Consultation-liaison psychiatrists on bioethics committees: opportunities for academic leadership. Acad Psychiatry 2006; 30(5):416-21.

    2. Zaimes JM, Thompson TL 2nd: Opportunities for consultation-liaison (medical-surgical) psychiatrists to enhance residency recruitment. Psychosomatics 1994; 35(5):423-6.

    3. Parker R, Chapman D, Notaras L: "Big MAC": the role of consultation liaison psychiatry in hospital medical advisory committees. Australas Psychiatry 2011; 19(5):426-30.

    Objectives:

    1. Identify practice patterns and career paths of female psychiatrists who are boarded in consultation-liaison psychiatry in Ohio.
    2. Identify pratice patterns and career paths of psychiatrists who are boarded in consultation-liaison psychiatry.
    3. Identify role of consultation-liaison psychiatrist in integrated behavioral health care.

    Relevance:
    To demonstrate the varieties of practice options and how those choices integrate with other medical specialities.

     
  5. Meeting the Continuing Education Needs in Behavioral Health for Advanced Practice Providers
    Presenting Author:  Sarah Rivelli
    Co-Authors:  Virginia O'Brien, Marvin Swartz

    Purpose: Advanced practice providers (APPs), such as nurse practitioners and physician assistants, frequently care for patients with mental health problems yet have little access to ongoing education in this area. Such providers often work in underserved areas or primary care and may have key roles in collaborative care. We developed a blended learning offering for APPs in behavioral health to aid in the development of this key workforce. This intervention includes face-to-face didactics, web-based review and case discussion, group phone supervision and a web-based learning center. This intensive program aims to expand mental health care delivery in North Carolina by offering APPs up to date information about the recognition, evaluation, and treatment of mental illness.

    Methods: The educational program is divided into adult and child sections, each consisting of 3 days of in-person didactics, 5 follow-up themed webinars, 5 monthly case conferences, and a website with supporting articles, rating scales, treatment guidelines, and links to other educational sites. Participants opt to take both child and adult portions of the course, or choose just one. Face-to-face adult and child sessions include core topics in depression, anxiety, bipolar disorder, psychosis, substance abuse, policy, ethics and general health issues for individuals with mental illness. Participants provide demographic information about themselves, complete pre and post-tests on their knowledge and attitudes and record information on metabolic monitoring on patients prescribed second generation antipsychotics before and after participation in the course.

    Results: Two cohorts have participated thus far, with providers coming from a wide variety of practice settings which include primary care, inpatient and outpatient mental health. Providers from the first cohort note increased confidence in a number of areas after the intervention (overall average score on a 1-5 Likert scale was 2.85 pre-intervention versus 3.80 post intervention). The large majority of participants (87%) agreed or strongly agreed that the offering "will enhance the care of my patients with behavioral health needs." There was difficulty obtaining patient-level data due to the lack of a common electronic medical record across providers and some practice settings did not lend themselves to monitoring for metabolic syndrome. From the very limited patient-level data obtained, there did not appear to be any significant difference in monitoring after the intervention.

    Conclusions: This blending learning intervention for APPs is an effective way of meeting the continuing education needs in behavioral health for such practitioners. Whether this intervention will improve patient care directly requires further exploration.

    Objectives:

    1. Illustrate a contuining education offering for advanced practice providers.
    2. Describe the background and knowledge of advanced practice providers working in behavioral health.
    3. Report on the impact of a blended learning offering in behavioral health on attitudes, knowledge, and outcomes.

    Relevance:
    Advanced practice providers are a key workforce to be developed for collaborative care and consultation models.

     
  6. The Other Side of the Mirror: A Medical Student’s Perspective on Psychosomatic Medicine Rotation
    Presenting Author:  Guitelle St. Victor
    Co-Authors:  Madhavi Latha Nagalla, Damir Huremovic

    Purpose: To explore and understand medical students' attitude towards rotating through Psychosomatic Medicine service as a part of their 3rd year clerkship. Acknowledging their experiences and their feedback can help modify and improve the overall clerkship experience.

    Method: From February 2012 to February 2013, 30 students from the American University of the Caribbean were surveyed in a Psychiatry clerkship at Nassau University Medical Center.

    Description: The psychiatry rotation lasts six weeks with three weeks on inpatient service and three weeks on Consult-Liasion service. During this rotation, students interact with fellow, second and fourth year residents, psychology externs and interns and two psychosomatic medicine attendings. At the end of the rotation, students were asked to discuss the pros and cons of the psychosomatic medicine rotation.

    Discussion: Students discussed that they liked the autonomy, one-on-one interaction with the attending, and the good mix of cases. They discussed that this rotation is more practical for students who do not want to go into psychiatry. They felt that this rotation helped them improve their interpersonal communication skills, be better team players, obtain a better understanding about the side effects and interactions of psychotropics. They also liked the physical activity and the fact that they do not feel locked down on the floors as it happens in inpatient psychiatry. However, students felt that the service was unpredictable and demanded longer hours compared to inpatient psychiatry. They discussed that the first week was very overwhelming and required more orientation by the residents and fellows especially regarding the systems-based practice.

    Conclusion: 90% of the students reported that the long hours did not allow them to prepare enough for the shelf exams. However, they all reported that the autonomy and working at the interface of medicine and psychiatry helped them gain a better understanding of psychiatry. They were willing to choose the rotation again if they had to.

    References:

    1. Weddington WW Jr, Hine FR, Houpt HL, Orleans CS: Consultation-liaison versus other psychiatry clerkships: a comparison of learning outcomes and student reactions.

    2. Yano B, Markoff R, Alexander L, Hicks R: An alternative model for the psychiatric clerkship.

    3. Bourgeois JA, Kahn D, Servis M: Reflections on psychosomatic medicine as a third year medical student clerkship: an integrated experience that demonstrates the biopsychosocial model.

    4. Harsch HH, Young LD: The psychiatric rotation: traditional inpatient or consultation clerkship?

    5. Griffin, Phillip, et al: Consultation-liaison and inpatient psychiatry clerkships: comparison of learning outcomes and student attitudes.

    Objectives:

    1. To be aware of medical students’ opinion about psychosomatic medicine rotation as part of the third-year clerkship.
    2. To help medical schools understand the importance of exposing third-year medical students to psychosomatic medicine experience.
    3. We hope to incorporate psychosomatic medicine rotation in future curriculum for the third-year medical students.

    Relevance:
    This paper will illustrate the medical students' perspective of the importance of a psychosomatic medicine rotation and how we can modify and improve their clerkship experience.

     
  7. WITHDRAWN
     
  8. The Birth of a Teaching Service in the Wake of Hurricane Sandy
    Presenting Author:  Elyse Weiner
    Co-Author:  Brian Bronson

    Hurricane Sandy devastated the northeast in an unpredicted and unprecedented manner. Part of the resultant disruption involved the evacuation and closure of all of the New York University (NYU) affiliates along First Avenue. These measures entailed the immediate shut-down of NYU-Langone Medical Center, Bellevue Hospital Center, and the Department of Veterans' Affairs (VA) New York Harbor Health Care System New York Campus, leaving patients without a hospital, staff without jobs, and students/trainees without schools. To complete their training on time, residents and medical students had an urgent need for positions.

    As part of the VA New York Harbor Health Care System, the Brooklyn Campus had many links with the New York Campus prior to the storm. The Brooklyn Campus, therefore, could spring into action, absorbing large numbers of patients and staff. This abstract is the story of how in less than a month, an academic consultation-liaison psychiatry service was created, transforming the practice from a single attending per day covering all consults into a full teaching service.

    Over the first month, a team took shape with trainees from various disciplines. The first to arrive was the attending on 11/5/12. The consultation-liaison fellow and a PGY 4 in psychiatry did not start until 11/13/12, so teaching rounds began mid-month. Over the next two weeks, a PGY2 in psychiatry, a neurology resident, a pain fellow, a health psychology intern and medical students often joined rounds. The trainees have been steadfast in their unanticipated journey to the end of Brooklyn. Their commutes went from negligible to over an hour and a half by public transportation, most needing two trains and a bus.

    Many loyal patients and families also had to travel great distances to receive care at the Brooklyn VA. Two additional medical units were opened to accommodate the influx of patients. The facility expanded its medical and surgical bed capacity from 117 to 173 beds, a 48% increase. The number of consultation encounters, including initial and follow-up visits, increased from 81 in September and October before the storm, to 184 during the subsequent January and February, representing over a 100% growth in activity.

    As of this writing, our story is not complete. There continues to be an academic consultation-liaison service at the Brooklyn Campus of the VA New York Harbor Health Care System. With the re-opening of the inpatient medical units in New York slated for before July 1, 2013, the Brooklyn Campus will most likely return to the model of a single attending providing consults to the general medical hospital. Thanks to our dedicated trainees, we have learned that we can create a fully functioning teaching service in essentially two weeks.

    Objectives:

    1. To understand how mentors can help trainees to continue pursuing their academic goals in the midst of an emergency.
    2. To use this circumstance to better understand how we can increase preparedness should a sudden disruption of clinical care occur.
    3. To demonstrate that despite a crisis, academic and clinical care can not only continue but even flourish.

    Relevance:
    This presentation is relevant to consultation-liaison psychiatrists who may be impacted by the emergency closure of a nearby medical facility.

     
  9. Can Psychiatric Residents Be Effectively Integrated into a Telemedicine Primary Care Collaborative?
    Presenting Author:  John Wells

    Purpose: The Louisiana Mental and Behavioral Health Capacity Project, part of the Gulf Region Health Outreach Program, is tasked with providing "assessment, consultation, training, prevention, and education services" to federally qualified health centers and community primary care clinics in designated parishes along the coast of Louisiana. Under this project, Louisiana State University Health Sciences Center Department of Psychiatry is offering mental and behavioral health consultation to primary care clinicians using a collaborative care model combining on-site service with telemedicine.

    One of the most challenging and potentially rewarding aspects of this program has been the inclusion of psychiatric resident training into this consult service. Residents are typically trained in settings including psychiatric office practices, inpatient psychiatric units, and hospital consult-liaison services. In contrast, the collaborative care model embeds the psychiatrist, and thus the training resident, into a primary care setting based team. Including residents into this framework in an integrated fashion requires that the resident provide expert consultation in a real-time manner to a multidisciplinary treatment team.

    Concerns not commonly addressed in traditional training settings include use of telemedicine and coordination with psychologists for brief symptom-based interventions. Residents practice normalizing treatment of anxiety and depression as chronic care issues on par with hypertension, diabetes, and asthma, including pro-active follow-up.

    Methods: We are working closely with psychologists and primary care providers to effectively include residents into this collaborative care initiative. The resident must triage referred patients for appropriateness for treatment in a primary care setting, and address any acute safety concerns. Once triage is complete, the resident must assess the patient, develop a plan with the treatment team, and disseminate the plan for implementation. Residents are responsible for registering their patients and pro-actively providing interval follow-up to assess adherence and response. We provide direct supervision by staff psychiatrists.

    Results: A rotation for third-year psychiatry residents combining on-site visits to selected primary care clinics with telemedicine. A field manual which contains descriptions of the issues delineated above, reference materials, standardized screens and measures, and treatment protocols.

    Conclusions: As collaborative care initiatives become more common, and as telemedicine becomes a mainstream modality for the provision of psychiatric care, the need for psychiatrists trained in these approaches will increase. This program begins to address these challenges to better equip the next generation of doctors for the new face of health care.

    Objectives:

    1. Be able to incorporate a resident training program into one's collaborative care efforts.
    2. Be able to apply the available data concerning the use of brief symptom-based interventions to facilitate a collaborative mental and behavioral health initiative.
    3. Be able to discuss the need to normalize the treatment of common mental and behavioral disorders with other chronic diseases found in primary care settings.

    Relevance:
    As the need for psychiatrists expert in the provision of collaborative care increases, resident training must accommodate by including the basic tenets of collaborative care in the core curriculum.

     

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Section J:  Transplant

  1. Face Transplantation: Psychological Outcomes at Year Four
    Presenting Author:  Kathy Coffman
    Co-Author:  Maria Siemionow

    Objectives: Investigate long-term psychological outcomes with facial transplantation.

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

    Results: Appearance self-rating rose from 3/10 prior to transplantation to 7/10 afterwards. Anxiety about body image and the Facial Anxiety score both fell in half by the third year, but rose somewhat the end of year 4 due to weight gain and an episode of rejection. Health care orientation, Rosenberg Self-Esteem scores, Spielberger State/Trait anxiety scores and WHO-QOL-BREF on all 4 domains have remained virtually unchanged over the four years. Beck Depression Inventory fell from16 pre-transplant to 10 by the end of year 4. Pain was 6-7/10 prior to transplant and 0/10 by day 50. Perception of Teasing-FACES scores fell from 25 to 8 by year 4. The Social Environment Domain of the PAIS-SR improved from 15 to 0 midway through year 4, ended year 4 at 7. This score is lower in summer. PAIS-SR Psychological distress is nearly unchanged numerically, but appears to be rated on a whole different scale of difficulty now, as a pimple on her nose can provoke distress whereas prior to face transplant the patient had no nose.

    Conclusions: The major limitations of this research are that these conclusions are based on a single female patient. Preliminary data from four male patients indicate that males may view their injuries differently, and may report less distress across the board on the PAIS-SR. Gender differences in body image and weight gain from steroids may be seen if more data is collected systematically to be able to track changes longitudinally. In addition, if male face transplant candidates start out with better quality of life on the PAIS-SR, improvements may be hard to demonstrate after facial transplantation. In addition, the risk/benefit ratio over time after face transplant may be different for men and women. Alcoholism as a risk factor for facial injury, and opiate dependence after injury and multiple surgeries are seen in men and women. Injury due to domestic violence and attempted homicide may prove to cause different psychological issues than facial injury due to suicide attempt (such as PTSD), whether the patient is male or female. In addition, injury due to military service or altruistic acts may raise different psychological issues. Collaboration across transplant centers is needed to answer these questions, since recipients only number about 20 in the world at this time. Longitudinal standardized data collection may quantitate psychological outcomes with facial transplantation to determine whether risks of immunosuppression over time are offset by improved quality of life.

    Objectives:

    1. Learn to investigate quality of life longitudinally in facial transplant recipients, and understand which instruments are more useful for analyzing change over time.
    2. Be able to consider gender differences in psychological aspects of facial injury and facial transplantation, and how this may confound assessment of risk/benefit ratio over time.
    3. Learn about the role of addiction in facial injury, and potential problems with recurrent addiction after facial transplantation regarding adherence with immunosuppression and appearance of the graft.

    Relevance:
    This presentation will investigate prognostic factors in patient selection, timing of the transplant, and gender differences observed so far in evaluation of 8 candidates, as well as longer term outcomes.

     
  2. [T] Demographic and Pretransplant Factors Associated with Interest, Knowledge, and Concerns about Living Kidney Donation
    Presenting Author:  Monica DeFeo
    Co-Authors:  Mencia Gomez, Patricia McDonough

    Background: Living donor kidney transplantation (LDKT) has been underutilized amongst minorities and little research is available on factors associated with interest, knowledge, and concerns about LKDT.

    Methods: Questionnaires were administered to kidney candidates on the kidney transplant waiting list as of January 1, 2011 at one kidney transplant center in the northeastern United States prior to attending a hospital-based support group. The questionnaire was administered to evaluate baseline awareness of list status (active/inactive) and coordinator name, contact frequency by coordinator, as well as LDKT stage, willingness to talk about LDKT, and knowledge and concern regarding LDKT. Univariate associations were examined using the chi-square tests for categorical variables and ANOVA for analysis of continuous variables. A P-value of less than 0.1 was considered significant.

    Results: Of 909 kidney transplant candidates, 161 attended the support group and filled out the questionnaire. Older candidate age was associated with higher rates of communication with the transplant coordinator (p=0.0657), but not LDKT interest, willingness to speak to potential donors, knowledge or concern. Indian and Latino race was associated with lower knowledge regarding list status (p=0.0804), less LDKT knowledge (p=0.0107) and greater LDKT concern (p=0.0154). The nephrologist, surgeon, and coordinator team 1 was associated with lower awareness of coordinator name (p=0.0273) and team 3 was associated with less candidate and coordinator communication (p=0.0749), but there were no associations with LDKT assessments and transplant team constitution. Candidates for whom at least one potential donor made an interest call to the transplant center scored higher in terms of LDKT interest (p=0.0311) and willingness to speak to potential donors (p=0.0715).

    Conclusions: These results demonstrate that candidates with potential donors score higher in interest and willingness to talk about LDKT suggesting that candidate motivation is an important component in identifying living donors. Indian and Latino minorities had lower knowledge scores and higher concern scores about LDKT suggesting that specific educational programs should be created to target these groups in order to overcome some barriers to LDKT.

    Objectives:

    1. Identify barriers that decrease willingness of renal transplant candidates to openly discuss living donation with potential donors.
    2. Evaluate and address the concerns of renal transplant candidates towards live kidney donation.
    3. Identify how a culturally sensitive educational program about live kidney donation in major transplant centers can potentially increase utilization of living donation in minority populations.

    Relevance:
    Our study determined that the lack of education about live kidney donation not only increased concerns but was a barrier to live kidney donation in specific minority populations.

     
  3. Should We Transplant Patients with Fulminant Liver Failure from “Unintentional” Acetaminophen Overdose?
    Presenting Author:  Anne Eshelman

    Acetaminophen is a common analgesic, safe in therapeutic doses. It is an active ingredient found in more than 600 over-the-counter and prescription medicines, including pain relievers, fever reducers, cough suppressants, and cold medicines. Acetaminophen is also responsible for 60,000 overdoses, 26,000 hospitalizations, and 450 to 500 deaths each year. It is the most common cause of acute liver failure in the US and accounts for 40% of all overdoses, 10% of which develop severe liver damage and 2% develop acute liver failure.

    This presentation will review the literature on fulminant hepatic failure due to "unintentional" acetaminophen overdose, including natural history, treatment options, recovery with supportive care, and decisions about liver transplant in the context of a case of a young man who was chronically abusing pain medications and presented in liver failure.

    With unintentional overdoses, self-harm is not the aim. 79% are chronically overusing combinations of acetaminophen and opioids for pain control, and 38% use more than 1 acetaminophen preparation. Morbidity and mortality are greater with unintentional overdoses compared to a single ingestion suicide attempt, due to delay in treatment, and subsequent ineffectiveness of detoxification with activated charcoal or n-acetylcysteine. Chronic overuse, with repeated staggered overdoses, may present with lower drug levels on admission, but is more likely to develop hepatic encephalopathy,and systemic organ failure.

    Ethical issues in decision to transplant, including beneficence and justice, are discussed. This young man had been chronically overusing Vicodin from multiple prescribers for chronic back pain since a car accident, 1 1/2 years prior, when he was injured by a drunk driver. He met criteria for Pain disorder with psychological and physical factors, and opioid and nicotine dependence, as well as hepatic encephalopathy. He was high risk for relapse into overuse of narcotic/acetaminophen combination drugs, and the liver transplant team declined him for transplant. Liver transplant can save some lives and be successful, if patients are effectively treated for addiction and can maintain abstinence.

    Some overdoses are classified as "therapeutic misadventures," accidental overdoses while intoxicated, due to confusion and cognitive impairment, or due to lack of awareness of dangers of multiple acetaminophen products. Transplant psychiatry needs to sort out the history and circumstances behind the overdose in order to assess risk. There is no consensus across programs in transplanting those with fulminant liver failure who overuse pain medications. Recommendations for assessment and treatment are provided.

    References:

    1. Karvellas C, et al: Medical and psychiatric outcomes for patients transplanted for acetminophen-induced acute liver failure: a case-control study. Liver International 2010; 826-833.

    2. Craig, et al: Overdose pattern and outcome in paracetamol induced acute severe hepatotoxicity. BJCP 2011; 71:2, 273-82.

    Objectives:

    1. Analyze risks with unintentional overdose of acetaminophen resulting in acute fulminant liver failure.
    2. Apply knowledge of acetaminophen overdose to decision making in liver transplant candidates.
    3. Create recommendations for assessment and treatment of pain patients with overuse of opiate/acetaminophen combinations.

    Relevance:
    Acetaminophen is responsible for 60,000 overdoses and 26,000 hospitalizations yearly in the US, and 40% of all overdoses. 10% develop severe liver failure and may be evaluated for liver transplant.

     
  4. [T] Comparison of Two Hospital Educational Approaches to Increase Live Donor Kidney Transplantation Amongst Minorities
    Presenting Author:  Mencia Gómez De Vargas
    Co-Authors:  Aws Aljanabi, Carmen Velez, Liise Kayler, Monica DeFeo, Patricia McDonough, Paula Marcus

    Background: Living donor kidney transplantation (LDKT) has been underutilized amongst minorities and little research is available on how to reduce racial/ethnic disparities.

    Methods: Active candidates on a waiting list at one transplant center in New York were invited to attend one of two different hospital-based educational approaches: 1) a pre-transplant support group (SG) that provided standard education regarding LDKT; or 2) a didactic educational class (E) specifically aimed at LDKT education which introduced the concept of donor advocacy by friends/family. Candidates were encouraged to invite a guest. The LDKT group was culturally sensitive for Hispanics, including using a minority health educator and groups conducted in Spanish. A self-report questionnaire evaluated baseline awareness of list status, LDKT stage, willingness to talk about LDKT, knowledge and concerns regarding LDKT.

    Results: Of 416 candidates, 65 were excluded since a donor had been identified prior to the invitation, 32 were excluded due to deceased-donor transplantation before or within 3 months of group meeting. 54 were excluded for at least one of the following reasons: patient could not be reached, delisting, change to status 7, expired, or moved to other center. The remaining 265 constituted the study cohort and included 56 (21.1%) who attended the SG, 54 (20.4%) who attended the E and 155 (58.5%) who declined to attend (control). Analysis showed the control group to be comprised of younger candidates on average. The educational group was comprised of greater proportions of Latinos and a smaller proportion of African-Americans compared to the other groups. Attendees scored higher on interest in LDKT (p=0.0318) and after a 3-month follow-up, 16 living donor inquiries (3.8%) were made. Patients in the educational group were more likely to have had at least one living donor inquiry (18.5%) compared to those in the support group (1.8%, p=0.0037) or the control group (3.2%, p=0.0007). Of the inquiries in the educational group 8 were for Latino candidates and 2 for African-American candidates, resulting in a live donor inquiry rate of 33.3% (8 of 24) for Latinos and 25% (2 of 8) for African-Americans that attended the educational group.

    Conclusions: These results suggest that a LDKT-specific education program can overcome some barriers to LDKT in minorities. Additionally, a program that is culturally sensitive appears especially beneficial to increase awareness specifically in Hispanic populations. However, the higher baseline interest in LDKT amongst patients choosing to attend the educational group suggests a selection bias and perhaps greater baseline motivation to seek LDKT.

    Objectives:

    1. Understand how minority groups are more receptive to education presented in a way that is culturally acceptable for them.
    2. Review activities aimed at reducing concern and effective at creating interest in potential donors.
    3. Identify the limitations that prevent receptors from obtaining live donors in a transplant center in the South Bronx.

    Relevance:
    Our study determined that by addressing our receptors concerns and by educating, the interest in live donation increased.

     
  5. Psychosocial, Ethical, and Medical Issues in a Multiple Liver Transplant Recipient Seeking Another Liver Transplant
    Presenting Author:  Shehzad Niazi
    Co-Authors:  Andrew Keaveney, Adriana Vasquez, Maria Yataco, Terry Schneekloth, Sheila Jowsey, Teresa Rummans

    Purpose: Orthotopic liver transplant (OLT) is a life saving option for patients with terminal liver disease. Nationwide acute shortage of organs means that not every patient who is seeking transplant can receive one. According to Scientific Registry of Transplant Recipients (SRTR) there were 16,747 patients at the start of the waiting list in 2010-2011. After 6,094 OLTs, 1,589 deaths, 11,925 new patient listings and attrition due to other reasons, 16,867 patients were still on the waiting list [1]. Survival rates after OLT have steadily improved to more than 80% one-year survival and over 60% five years survival [2]. Jain et al [3]reported poorer outcomes after retransplant (Re-OLT). When compared to primary OLT, 10-year survival rate for Re-OLT was reported as 32% for second, 25% for third, and 13% for fourth or more transplants [3]. Considering more demand than supply in the context of escalating healthcare costs, Re-OLT poses challenging questions about selection criteria, assessment process, ethical considerations, and cost effectiveness [4, 5].

    Methods: We describe a case of a multiple OLT recipient seeking Re-OLT to highlight some of the psychosocial and ethical as well as medical issues in evaluating patients for Re-OLT.

    Results: At MCF, 34 patients have received Re-OLT since January 2010. We evaluated a middle-aged patient with remote history of poly-substance dependence, alcoholic cirrhosis, and hepatitis C for possible Re-LT. He had undergone multiple Re-OLTs over the years for various reasons. At the time of admission, he was dealing with multiple medical comorbidities. Psychiatry was consulted for pretransplant evaluation. He had some compliance issues in the recent past. The patient had maintained his sobriety since his 20's and had an extensive support system. We assigned him a PACT score of 0.5 to 1 considering psychosocial issues. After a detailed multidisciplinary evaluation, he was denied Re-OLT due to a low PACT score and medical comorbidities.

    Discussion: This case illustrates the ethical issues, prognostic factors, and psychosocial considerations in assessing patients requiring Re-OLT.

    1. Scientific Registery of Transplant Recepients: Aggregate National Reports <http://srtr.org/csr/current/nats.aspx>.

    2. Busuttil RW, et al: Analysis of long-term outcomes of 3200 liver transplantations over two decades: a single-center experience. Ann Surg 2005; 241(6):905-16; discussion 916-8.

    3. Jain A, et al: Long-term survival after liver transplantation in 4,000 consecutive patients at a single center. Ann Surg 2000; 232(4):490-500.

    4. Zimmerman MA, Ghobrial RM: When shouldn't we retransplant? Liver Transpl 2005; (11 Suppl 2):S14-20.

    5. Biggins SW, et al: Retransplantation for hepatic allograft failure: prognostic modeling and ethical considerations. Liver Transpl 2002; 8(4):313-22.

    Objectives:

    1. Be able to understand prognosis of retrasnplant.
    2. Be able to understand ethical issues involved in psychosocial evaluation of liver retransplantation.
    3. Be able to understand that supply and demand discrepancy poses unique challenges in making decision about retransplantation.

    Relevance:
    Transplant psychiatrists and other C-L psychiatrists will become aware of unique challenges in making clinical decisions in the unique situation of dealing with multiple retransplant patients.

     
  6. [T] Factitious Disorder in a Patient with Small Bowel Transplant
    Presenting Author:  Neil Puri

    Purpose: The purpose of this poster is to increase awareness of factitious disorder in the transplant population.

    Method: A case description followed by a discussion.

    Results: The patient is a female who underwent a small bowel transplant at the age of 26 for short gut syndrome related to complications from gastric bypass she had at age 20. Her hospital course after transplant went as planned with minimal complications. A year after transplant, she was repeatedly admitted to the hospital for polymicrobial bacteremia. During some of the hospitalizations, staff found syringes in her room. She was seen by psychiatric consultants. The possibility of factitious disorder was discussed with her using face saving techniques. She denied all self-harm and denied all knowledge of the syringes. She was offered psychiatric hospitalizations, but declined them. She did, however, agree to outpatient therapy. During one admission, she became septic and lost her graft. During that hospitalization a syringe was again found in her room. She felt she was being accused and chose to transfer her care to another hospital. While at the other hospital, she again had polymicrobial bacteremia. Her room was searched and staff found syringes filled fecal matter. Her condition improved after the search and she was sent home. A few days after discharge, she was found dead in her home. The presumed cause of death was sepsis.

    Conclusions: Factitious disorder provides many challenges in the clinical setting. There are only two case reports of factitious disorder in the organ recipients [1,2] and none for a recipient of a small bowel. Factitious disorder is motivated by a desire to assume the sick role. Many transplant patients have had long periods of significant sickness and have developed significant relationships with transplant teams. After transplant, they are no longer as sick and no longer require as frequent contact with the transplant team. Feigning or causing illness may become a strategy to decrease the stress of adjusting to a new lifestyle and fear of losing the relationship with the transplant team. Clinicians should be aware that patients undergoing transplant may be at particular risk for developing a factitious disorder. Furthermore, given the medical comorbidities, diagnoses of factitious disorder may be more difficult in transplant patients. Thus, clinicians should be keenly aware of laboratory and exam findings that can aide a diagnosis of factitious disorder.

    References:

    1. Donegan D, Hickey DP, Smith D: Hypoglycemia after simultaneous pancreas-kidney transplant: fact or factitious? Pancreas 2012; 41(6):974–6.

    2. Nishimura K, Oshibuchi H, Kobayashi S, et al: Graft loss in a living kidney transplant patient with Munchausen syndrome. Psychosomatics 2011; 52(4):394–5.

    Objectives:

    1. Understand the unique psychological risks transplant patients may have for factitious disorder.
    2. Be able to investigate factitious disorder in populations with high medical comorbidity.
    3. Understand management techniques for transplant patients with factitious disorder.

    Relevance:
    Factitious disorder carries high risks in the transplant population. Being aware of its causes, diagnoses, and potential management will be important to mitigate these risks.

     
  7. Substance Abuse and Hematopoietic Progenitor Cell Transplantation
    Presenting Author:  Isabel Schuermeyer
    Co-Authors:  Michele Cooper, Ronald Sobecks

    Purpose: Most patients that undergo a hematopoietic progenitor cell transplant (HPCT) have psychosocial screening done as part of the pre-HPCT evaluation. There is only one article that showed via a small, retrospective review that there are worse outcomes for patients with substance abuse. Despite the limited data on alcohol dependence, another study asked department chairs of HPCT programs which factors would lead them to deny HPCT. Alcohol abuse is one of these factors. Regardless of this, HPCT selection committees vary on deciding on whether or not they will transplant an active abuser and what kind of chemical dependency treatment they would want prior to transplant.

    Methods: Three cases of patients with history of substance abuse, as well as active use during the prescreening process will be reviewed. The first case is that of a young man who required HPCT for acute promyelocytic leukemia who was found to have opiate abuse. The second case is of a middle aged man diagnosed with mantle cell lymphoma and alcohol abuse. The last case is of a middle aged woman with chronic lymphocytic leukemia who was found to have alcohol dependence as part of the pre-HPCT evaluation.

    Results: Of these three cases, the first patient went through the HPCT process, with some chemical dependency treatment prior and later has continued to have problems with opiate dependence. The second patient committed suicide after the HPCT. The third patient remains in chemical dependency treatment that was required by the selection committee prior to proceeding to HPCT.

    Conclusions: There needs to be more research on the impact of substance abuse on patients undergoing HPCT, as this life-saving treatment should not be withheld unless there is clear evidence of worse outcome.

    Reference:

    1. Chang G, Antin JH, Orav EJ, Randall U, McGarigle C, Behr HM: Substance abuse and bone marrow transplant. Am J Drug Alcohol Abuse 1997; 23(2):301-8.

    Objectives:

    1. Survey the limited data on the risk of substance abuse in patients undergoing HPCT.
    2. Review the data we obtained and learn from these the potential risks for these patients.
    3. Learn the importance of pre-screening patients undergoing HPCT and understand the rationale behind the recommendations for treatment prior to HPCT, if medically feasible.

    Relevance:
    As HPCT becomes more common, it is important that the risks of psychiatric illness, especially substance abuse, be fully understood, so that this life saving treatment is not withheld unnecessarily.

     
  8. An Insatiable Desire for Tofu: A Case of Anxiety and Restless Legs Triggered by Microcytic Anemia in a Transplant Patient
    Presenting Author:  Yelizaveta Sher
    Co-Author:  Jose Maldonado

    Purpose: To remind psychosomatic medicine physicians about a constellation of behavioral symptoms that can present in iron deficiency.

    Methods: We discuss the case of behavioral symptoms caused by microcytic iron-deficient anemia. The relevant literature is reviewed.

    Results: Fifty three year old vegetarian woman, two years status post bilateral lung transplant for treatment of cystic fibrosis, was referred to psychiatry for anxiety. The patient complained of "disturbing and constant need to move my legs at night" making her sleep difficult. She had been prescribed 2 mg of lorazepam nightly by her transplant team. In addition, the patient complained of daily fatigue. Moreover, she gained weight due to her "irresistible urge to eat tofu." Her labs were significant for microcytic anemia with hematocrit (Hct) of 25.8 and mean corpuscular volume (MCV) of 70.6. Blood Iron (Fe) level and ferritin were exceedingly low at 2 (normal range 5-114) and 13 (normal range 20-160). She was prescribed replacement with iron at 325 mg orally three times a day. Three months later, the patient no longer experienced restless leg syndrome (RLS), did not require lorazepam, and had improved energy. Moreover, she no longer craved or even enjoyed tofu. Repeat labs revealed Hct of 41.4, MCV - 94.4, Fe - 117, and ferritin - 20.

    Discussion/Conclusions: The patient's restless legs, anxiety, fatigue, and tofu cravings appeared to be due to her profound iron deficiency and were resolved with iron replacement. RLS has been described in patients with iron deficient anemia [1], although there is no definitive recommendation to treat all RLS patients with iron. Also, pica, usually described as the craving of non-foods, frequently accompanies iron deficient anemia [2]. Most often, patients with iron deficiency and pica crave ice or clay, but there are reports of cravings of tomatoes and lemons. It is not surprising that our vegetarian patient craved tofu as tofu can be a good source of iron. On the other hand, tofu is similar in texture to clay, and it has been postulated that one of the mechanisms behind geography (eating earth/clay) is protection from toxins and parasites. Geogaphy is more prevalent in populations more susceptible to such dangers: preadolescents and pregnant women [3]. It is possible that our patient's immunosuppression added to her risk of developing pica.

    References:

    1. Allen RP et al: The prevalence and impact of restless legs syndrome on patients with iron deficiency anemia. American Journal of Hematology 2013.

    2. Kettaneh A, et al: Pica and food craving in patients with iron-deficiency anemia: a case-control study in France. The American Journal of Medicine 2005.

    3. Young SL, et al: Why on earth?: Evaluating hypotheses about the physiological functions of human geophagy. The Quaterly Review of Biology 2011.

    Objectives:

    1. Be able to recognize the behavioral symptoms of iron deficient anemia,
    2. Be able to order appropriate tests to diagnose iron deficient anemia and appreciate treatments for restless leg syndrome,
    3. Appreciate various theories behind pica syndrome especially as relevant to medically ill populations, including mineral deficiencies and protection from toxins,

    Relevance:
    The presentation will remind the psychosomatic medicine physicians the importance of being a physican first. The audience will be able to recognize the behavioral symptoms of iron deficient anemia.

     
  9. Depressive Symptoms Patients with Immunoglobulin Monoclonal Light Chain Amyloidosis Undergoing Stem Cell Transplantation
    Presenting Author:  Janet Shu
    Co-Authors:  John Berk, David Seldin

    Purpose: There is limited literature examining the prevalence and significance of depression in patients being treated for systemic amyloidosis, complex diseases caused by protein misfolding that leads to progressive organ damage [1]. Stem cell treatment and chemotherapies have been developed to treat immunoglobulin monoclonal light chain amyloidosis (AL). These therapies have extended patients’ lifespans in a serious disease with poor prognosis [2]. As patients recently have been able to have better survival rates, they have greater time to cope with the emotional consequences of their diagnosis. There is a unique opportunity to explore how depression interplays with treatment of amyloidosis, and to compare it with other hematopoietic malignancies.

    Methods: Systematic review of literature from 1990 to 2012 using PubMed terms “depression” “systemic amyloidosis” and/or “stem cell transplantation,” as well as cross-referencing from bibliographies of found articles.

    Results: Limited publications address the important issue of depression in patients being treated for AL amyloidosis. One prospective cohort study found that stem cell transplantation improved quality of life for amyloid patients [3]. More literature is available studying the association of depressive symptoms in patients receiving stem cell transplant as treatment of a cohort of malignant diseases, including leukemia, multiple myeloma, and amyloidosis [4].

    Conclusion: More research is needed to study the role of depressive symptoms in patients with AL amyloidosis. Seldin et al found overall improvement of quality of life in AL amyloidosis patients who received combination chemotherapy and stem cell therapy, but did not specifically analyze depressive symptoms [3]. Review of other hematologic malignancies has shown a significant number of patients who experience depressive symptoms before, during, and after stem cell transplantation [4]. Further studies will help clarify whether AL amyloidosis, as a subpopulation of hematologic malignancies requiring stem cell transplantation, shows similar trends regarding depression.

    Objectives:

    1. Review current literature examining depressive symptoms in patients with amyloidosis undergoing stem cell therapy.
    2. Understand how a rare disease with poor prognosis can impact patients' mood and functioning.
    3. Apply knowledge to consultations involving patients with serious illness and comorbid psychiatric symptoms.

    Relevance:
    Review of published data about and increases awareness of depressive symptoms in the rare and potentially lethal disease of AL amyloidosis.

     
  10. [T] Psychopathology in Pancreas Transplant Recipients: A Review of 158 Cases
    Presenting Author:  Erin Sterenson
    Co-Authors:  Ajay Parsaik, Yogish Kudva, Terry Schneekloth, Sheila Jowsey, Teresa Rummans, Tamara Dolenc

    Background: Pancreas transplantation is a potential cure for insulin-dependent diabetes and can be life-saving in those with significant medical complications of diabetes and hypoglycemia unawareness. Patients with diabetes are at increased risk for developing clinically significant depression and anxiety. We hypothesize that a significant proportion of patients undergoing pancreas transplantation have psychiatric morbidity.

    Purpose: We wished to determine the prevalence of psychiatric illness in pancreas transplant recipients and its impact on post-transplant outcomes.

    Method: This was a retrospective chart review study of 158 patients who underwent pancreas transplantation at the Mayo Clinic between 2002 and 2012.

    Result: The average age at transplant was 44 years. The average HbA1c was elevated at 8.7 mmol/L. The majority of patients (72%) had at least one pre-transplant Axis I psychiatric diagnosis, most commonly depression and nicotine dependence. No patients were diagnosed with bipolar or psychotic disorders. In our group, 42(27%) patients experienced one or more episodes of graft rejection, and 49(31%) experienced partial or full graft failure. Neither graft rejection nor failure was attributed to immunosuppression non-compliance. In our group, 31(20%) patients died. No deaths were attributed to suicide or treatment non-compliance. In addition, no significant correlation was found between transplant outcome (graft rejection, graft failure, or patient death) and psychiatric diagnosis.

    Conclusions: Results of our retrospective chart review study showed a high prevalence of depression and nicotine dependence in pancreas transplant recipients. Prior diagnosis of psychiatric disorder did not correlate with worse post-transplant outcomes in our group.

    Objectives:

    1. To recognize the high prevalence of psychopathology among patients with diabetes.
    2. To recognize the high prevalence of depression and nicotine use among pancreas transplant patients.
    3. To explore the effects of psychiatric illness on post-pancreas transplant outcome.

    Relevance:
    Psychiatric disorders are common in pancreas transplant recipients. We review the effects of psychiatric illness on post-pancreas transplant outcomes.

     
  11. WITHDRAWN
     
  12. Donor Satisfaction in Living Kidney Transplantation from Donors Related to the Recipients—Part 1: After Donation, How Do Donors View Factors Associated with Decisions Involved in Donation?
    Presenting Author:  Junko Tsutsui
    Co-Authors:  Sayaka Kobayashi, Katsuji Nishimura, Sachi Okabe, Yoshie Okada, Hideki Ishida, Kazunari Tanabe, Jun Ishigooka

    Objective: To examine the satisfaction of living kidney donors who were related to the recipients with regard to organ donation and transplantation, and to develop a questionnaire for understanding the perceptions of donors concerning the results of donation and transplantation.

    Method: The factors related to decisions involved in living kidney donation that we identified in a previous qualitative study (Nishimura et al, 2009) were revised so that they could be described in terms suitable for past donors, for possible use as questionnaire items. The appropriateness of the items and their expression was examined by past donors and experienced transplantation staff, and a scale composed of 26 items in six categories was developed. The responses to each item were given on a five-step Likert-type scale, from “It is definitely so” to “It is definitely not so.”

    Results: Responses were obtained from 225 past donors (157 females [70%]; mean age: 56.6 ± 5.6 years; relationship with the recipient: 118 parents [54%], 72 spouses [32%], 23 siblings [10%] and 12 others [5%]). Response rates were studied for each item. More than 90% of the subjects responded “It is definitely so” or “It is usually so” to items such as “I think it was good that the recipient was freed from dialysis” and “I have confidence in the physician and hospital who carried out the transplantation” It was suggested that these are common perceptions among donors after kidney donation. On the other hand, only 51.5% of the subjects responded “It is definitely so” or “It is usually so” to “I did not wish a person other than myself to donate,” and 33.9% to “I was able to repay my obligation to the recipient by donating,” indicating that the perceptions of these items differ with each individual. No strong association between the demographic data and any of the items was found.

    Conclusions: It was confirmed that the questionnaire items relate to matters that are perceived as important by past donors. It was found that some items are perceived in a common way by most past donors, while for other items, there are individual differences. In the future, it will be necessary to clarify how these items are associated with satisfaction with regard to transplantation therapy and quality of life.

    Reference:

    1. Nishimura K, Kobayashi S, Okabe S, et al: Decision-making process involved in living kidney donation in Japan: a qualitative research study. Academy of Psychosomatic Medicine 56th Annual Meeting. Las Vegas, Nov. 11-14, 2009.

    Objectives:

    1. To analyze the perceptions of living kidney donors who were related to the recipients concerning the results of donation and transplantation.
    2. To analyze the satisfaction of living kidney donors who are related to the recipients with regard to transplantation therapy.
    3. To investigate how to understand psychological aspects of living kidney donors after donation.

    Relevance:
    To elucidate the perceptions of living kidney donors who were related to the recipients concerning the results of donation and transplantation on the basis of a qualitative approach.

     
  13. Donor Satisfaction in Living Kidney Transplantation from Donors Related to the Recipients—Part 2: Associated factors
    Presenting Author:  Katsuji Nishimura
    Co-Authors:  Sayaka Kobayashi, Junko Tsutsui, Sachi Okabe, Yoshie Okada, Hideki Ishida, Kazunari Tanabe, Jun Ishigooka

    Objective: Little information has been published on the satisfaction of living kidney donors who are related to the recipients with regard to transplantation therapy. The objective of this study was to clarify the factors associated with donor satisfaction.

    Methods: A questionnaire survey was conducted with 288 living-kidney donors related to the kidney recipients by mail, and 225 valid responses (78.1%) were obtained (157 females [70%]; mean age: 56.6 ± 5.6 years; relationship with the recipient: 118 parents [54%], 72 spouses [32%], 23 siblings [10%] and 12 others [5%]). The associations were studied between satisfaction with regard to transplantation therapy measured using 8-item Japanese version of the Client Satisfaction Questionnaire-8J (CSQ-8J; Larsen et al., 1979) and the following factors: sociodemographic data, health-related quality of life (QOL) as evaluated using SF-36, depression measured using the Self-rating Depression Scale (SDS), optimism measured using the Life Orientation Test, a 26-item questionnaire of donor perceptions which we developed on the basis of a previous qualitative study of decisions involved in living kidney donation (Nishimura et al., 2009), [A1]and the outcomes of the recipients, e.g., graft failure or success.

    Results:The mean total CSQ-8J score was 27.1 ± 3.3 (range 17 to 32). The total score for CSQ-8J showed somewhat significant correlations (r > .3) with the following items in the perception questionnaire: “There is no change in my health,” “Donation was consistent with my sense of values,” “My relationship with my family remains good,” “The information which I obtained in advance about the transplantation was sufficient,” “I have confidence in the hospital and physician who carried out the transplantation,” “The explanation which was given to me in the hospital was sufficient,” and “I was able to go ahead with examinations and transplantation after my feelings had been clearly decided.” No significant correlations were found among sociodemographic data, both physical and mental component summary scores of the SF-36, and optimism and depression scores.

    Conclusions: Our study suggested that the maintenance of their own health, sense of values surrounding donation, family relationships, access to information and confidence in medical treatment are associated with donor satisfaction with regard to living-donor kidney transplantation to relatives.

    References:

    1. Larsen DL, Attkisson CC, Hargreaves WA, et al: Assessment of client/patient satisfaction: development of a general scale. Evaluation and Program Planning 2, 1979, 197-207.

    2. Nishimura K, Kobayashi S, Okabe S, et al: Decision-making process involved in living kidney donation in Japan: a qualitative research study. Academy of Psychosomatic Medicine 56th Annual Meeting. Las Vegas, Nov. 11-14, 2009.

    Objectives:

    1. To analyze the factors associated with the satisfaction of living kidney donors who are related to the recipients with regard to transplantation therapy.
    2. To investigate the satisfaction of living kidney donors who are related to the recipients.
    3. To analyze how to provide the psychological care after living kidney donation.

    Relevance:
    To elucidate the factors associated with the satisfaction of living kidney donors who are related to the recipients with regard to transplantation therapy.

     
  14. Symptoms of Eating Disorder in Liver Transplant Recipients
    Presenting Author:  Paula Zimbrean
    Co-Author:  Sukru Emre

    Purpose: To assess presence of eating disorder symptoms in liver transplant recipients.

    Anorexia is the symptom that affects daily activities most frequently among all gastro-intestinal complications post liver transplant. [1]. Bulimia and binge eating disorder share disease features with addiction [2], which is common in liver transplant recipients [3]. To our knowledge, there is no data regarding the prevalence of eating disorders in liver transplant patients.

    Methods: 135 patients who received liver transplantation at our center between 1/1/2007 and 9/1/ 2011 were surveyed. The questionnaire included demographic information, Eating Attitude Test (EAT 26), Binge Eating Scale (BES), Hospital Anxiety and Depression Scale (HADS) and Short Form Health Survey (SF 36).

    Results: 32 questionnaires were returned (response rate of 30.1%). Average time since transplant was 2.5 ± 2.4 years. 7 (21.9%) respondents were within the first year posttransplant; 21 (65.6%) were male, 6 (18.8%) had received dual transplant (liver-kidney), 13 (40.6%) had a HADS anxiety subscore >8 and 8 (25%) had HADS depression subscore >8. At the time of the survey, 13 (40.6%) were obese, 12(37.5%) were overweight and 7 (21.9) % had normal Body Mass Index (BMI).

    Sixteen (50%) of respondents reported active binging on BES, with 5 (15.6%) reporting severe binging. Eleven (34.4%) screened positive for eating disorders on EAT: 3 (9.4%) had anorexic cognitions, while 9 (28.1%) had at least one behavior consistent with eating disorder. The most common behavior (6 subjects, 18.8%) was using laxatives, diuretics or pills to control the body weight or shape. Binge eating behavior was more common in liver kidney transplant than in liver only recipients (p=0.03). Anorexic cognitions tended to be present in liver-kidney recipients, compared to liver-only recipients (33.3% vs. 3.8% not statistically significant, p=0.08). The use of laxatives, diuretics or pills to control body weight or shape correlated with physical health scale of the SF-36 (p=0.04). Scores on the BES correlated with positive screening on EAT (p=0.008).

    Conclusions. Symptoms of eating disorder are present in a significant proportion of liver transplant recipients. More information is needed regarding the impact of these symptoms upon quality of life and transplant outcomes.

    References:

    1. Herrero JI. Benlloch S. Bernardos A., et al: MITOS Study Group. Gastrointestinal complications in liver transplant recipients: MITOS study. Transplantation Proceedings 2007; 39(7):2311-2313.

    2. Davis C, Carter JC: Compulsive overeating as an addiction disorder. A review of theory and evidence. Appetite 2009; 53(1):1-8.

    3. DiMartini A, Dew MA, Javed L, et al: The pre-transplant psychiatric and medical comorbidity of alcoholic liver-disease patients who received liver transplant. Psychosomatics 2004; 45:517-523.

    Objectives:

    1. Describe the impact of anorexia upon quality of life of liver transplant recipients.
    2. Describe the incidence of symptoms of eating disorder in liver transplant recipients.
    3. Describe the impact of symptoms of wating disorde upon quality of life in liver transplant recipients.

    Relevance:
    This study is assessing the presence of symptoms of eating disorders in liver transplant recipients and their impact on quality of life.

     

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