Consultation-Liaison Case Conference: Overcoming Bias in the Differential Diagnosis of Psychosis.

We present the case of a 34-year-old Black patient with no significant psychiatric history who presented with catatonia and psychotic symptoms following a recent severe acute respiratory syndrome coronavirus-2 infection, whose diagnosis of coronavirus disease 2019 encephalitis was delayed by premature attribution of his symptoms to a primary psychiatric etiology. Top experts in the consultation-liaison field provide guidance for this commonly encountered clinical case based on their experience and a review of the available literature. Key teaching topics include the diagnosis and management of coronavirus disease 2019 encephalitis, cognitive bias, and racial bias. Specifically, this case illustrates the role of the consultation-liaison psychiatrist in identifying medical conditions that may overlap with psychiatric presentations and in advocating for marginalized patients.

Race and Ethnicity and the Utilization of Security Responses in a Hospital Setting.

BACKGROUND: Security emergency responses (SERs) are utilized by hospitals to ensure the safety of patients and staff but can cause unintended morbidity. The presence of racial and ethnic inequities in SER utilization has not been clearly elucidated. OBJECTIVE: To determine whether Black and Hispanic patients experience higher rates of SER and physical restraints in a non-psychiatric inpatient setting. DESIGN: Retrospective cohort study. PARTICIPANTS: All patients discharged from September 2018 through December 2019. EXPOSURE: Race and ethnicity, as reported by patients at time of registration. MAIN OUTCOMES: The primary outcome was whether a SER was called on a patient. The secondary outcome was the incidence of physical restraints among patients who experienced a SER. KEY RESULTS: Among 24,212 patients, 18,755 (77.5%) patients identified as white, 2,346 (9.7%) as Black, and 2,425 (10.0%) identified with another race. Among all patients, 1,827 (7.6%) identified as Hispanic and 21,554 (89.0%) as non-Hispanic. Sixty-six (2.8%) Black patients had a SER activated during their first admission, compared to 295 (1.6%) white patients. In a Firth logit multivariable model, Black patients had higher adjusted odds of a SER than white patients (adjusted odds ratio (aOR) 1.37 [95% confidence interval: 1.02, 1.81], p = 0.037). Hispanic patients did not have higher odds of having a SER called than non-Hispanic patients. In a Poisson multivariable model among patients who had a SER called, race and ethnicity were not found to be significant predictors of restraint. CONCLUSION: Black patients had higher odds of a SER compared to white patients. No significant differences were found between Hispanic and non-Hispanic patients. Future efforts should focus on assessing the generalizability of these findings, the underlying mechanisms driving these inequities, and effective interventions to address them.

Impact and Prevalence of Physical and Verbal Violence Toward Healthcare Workers.

BACKGROUND: Threatening and assaultive behaviors against healthcare workers are a growing national concern.1,2,3 OBJECTIVE: To assess the incidence and impact of aggression against healthcare workers, a safety and quality improvement project was initiated in an academic, tertiary care, urban hospital. METHODS: Through the Northwestern Academy of Quality and Safety Initiatives program, an invitation to complete an online survey was sent to healthcare workers. The survey inquired about prevalence, location, and type of experience of physical or verbal abuse by patients or families. Other goals were: 1) worker knowledge and use of reporting systems, 2) effect on healthcare worker engagement, and 3) report of posttraumatic symptoms. RESULTS: 34.4% of healthcare workers reported any incident of verbal or physical violence in the preceeding 12 months, with 13.5% reporting physical assault. Of those with any incident of physical or verbal violence, 60.2% endorsed at least one posttraumatic symptom, 9.4% missed work, and 30.1% had thoughts about leaving their job or career. The reported impact was the same for physical or verbal incidents. DISCUSSION: Physical and verbal abuse of healthcare workers is prevalent and has a significant impact on employee engagement and posttraumatic spectrum symptoms. These results are based on a cross-sectional survey at one institution and may have a significant selection and response bias. CONCLUSION: Assessment of both verbal and physical aggression against healthcare workers should be standard. Front-line consulting psychiatrists and psychiatric programs for employee wellness could assess and manage this impact.

Health correlates of insomnia symptoms and comorbid mental disorders in a nationally representative sample of US adolescents.

STUDY OBJECTIVES: To estimate the prevalence and health correlates of insomnia symptoms and their association with comorbid mental disorders in a nationally representative sample of adolescents in the United States. DESIGN: National representative cross-sectional study. SETTING: Population-based sample from the US adolescents. MEASUREMENTS AND RESULTS: A total of 6,483 individuals aged between 13­18 y in the National Comorbidity Survey-Adolescent Supplement (NCS-A) with both individual and parental reports of mental health were included in this study. Participants were classified with insomnia symptoms if they reported difficulty initiating sleep, difficulty maintaining sleep, and/or early morning awakening, nearly every day for at least 2 w in the past year. Nearly one-third of adolescents reported insomnia symptoms for at least 2 w during the previous year. Hispanic and black youth were significantly more likely to report insomnia symptoms (42.0% and 41.3%, respectively) than non-Hispanic white youth (30.4%). Adolescents with insomnia symptoms were at a higher risk for all classes of mental disorders {odds ratio [OR] (95% confidence interval [CI]: 3.4 (2.9­4.0)} including mood, anxiety, behavioral, substance use, and eating disorders, suicidality [OR (95% CI): 2.63 (1.34­5.16)], poor perceived mental health [OR (95% CI): 2.01 (1.02­3.96)], chronic medical conditions [OR (95% CI): 1.94 (1.55­2.43)], smoking [OR (95% CI: 2.60 (1.00­6.72)], and obesity [OR (95% CI: 1.46 (1.10­1.93)] than those without insomnia symptoms. Adolescents with insomnia symptoms and comorbid mental disorders manifested even greater rates of these indicators of negative health behaviors and disorders than those with mental disorders alone (P < 0.05). CONCLUSIONS: Insomnia symptoms are reported by one-third of adolescents in the general population. Insomnia symptoms, even in the absence of concomitant depression or other mental disorders, are associated with serious health conditions, risk factors, and suicidality. Comorbid mental disorders potentiate the effect of insomnia symptoms on both physical and mental health. Further evaluation of the causes and effective interventions to reduce insomnia symptoms may have a significant effect on public health.

Oxytocin treatment in pediatric populations.

The role of endogenous oxytocin as neuromodulator of birth, lactation and social behaviors is well-recognized. Moreover, the use of oxytocin as a facilitator of social and other behaviors is becoming more and more accepted. Many positive effects have been attributed to intranasal oxytocin administration in animals and humans; with current research highlighting encouraging advances in its potential for use in mental health disorders. The new frontier will be investigating the effective use of oxytocin in pediatric populations. Limited animal data is available on this. Large-scale human studies focusing on autism are currently under way, but many other possibilities seem to lie in the future. However, we need to know more about the risks and effects of repeated use on the developing brain and body. This paper will provide an overview of the current understanding of the role of endogenous oxytocin and its related neuropeptide systems in influencing behaviors, in particular attachment, and will review (a) the literature on the use of intranasal oxytocin in young animals, children (age range birth-12 years) and adolescents (age range 13-19 years), (b) the expected benefits and risks based on the current research, and (c) the risks of oxytocin in children with severe psychopathology and early life trauma. The paper will conclude with a clinical perspective on these findings.