Patient and Medical Unit Staff Experiences of Proactive and Integrated Consultation-Liaison Psychiatry in The HOME Study: A Qualitative Investigation.

BACKGROUND: Consultation-liaison (C-L) psychiatry services aim to help general hospital staff provide better care for their patients. Recently, many inpatient C-L psychiatry services have adopted proactive and integrated approaches to achieve this aim. Despite these developments, there have been no interview-based studies of patients' and staff members' experiences of the new approaches. OBJECTIVE: To gain an in-depth understanding of patients' and medical unit staff members' experiences of a proactive and integrated C-L psychiatry service for older medical inpatients (Proactive Integrated C-L Psychiatry [PICLP]). METHODS: We conducted an interview-based qualitative study with thematic analysis. The participants were patients and staff who had experienced PICLP during The HOME Study, a randomized trial that evaluated PICLP in 24 medical units of three UK general hospitals. RESULTS: We conducted 97 interviews: 43 with patients or their proxies (family members who were interviewed on behalf of patients with significant cognitive impairment) and 54 with staff members of all relevant disciplines. Patients and staff both described how PICLP was a helpful addition to medical care and discharge planning. It enhanced the medical unit team's ability to address psychological, psychiatric, and social needs and provide patient-centered care. They welcomed proactive biopsychosocial assessments and the broader perspective that these offered on patients' complex problems. They also valued the integration of C-L psychiatrists into the unit teams and their daily contact with them. For patients, it fostered a therapeutic relationship and helped them to be more engaged in decisions about their medical care and discharge planning. For staff, it enabled ready access to psychiatric expertise and training opportunities. The few reported experiences of PICLP being unhelpful were mainly about the greater number of clinicians involved in patients' care and a lack of clarity about professional roles in the integrated team. CONCLUSIONS: We found that older inpatients and medical unit staff experienced PICLP as both acceptable and generally helpful. Our findings add to the existing evidence for the benefits of proactive and integrated C-L psychiatry services.

The use of hinged elbow orthosis following surgical management of terrible triad injuries of the elbow.

PURPOSE: To determine outcomes following surgical management of terrible triad injuries in patients treated with and without a hinged elbow orthosis (HEO) in the post-operative setting. METHODS: This study was a retrospective review of 41 patients who underwent surgical treatment of terrible triad injuries including radial head fracture, coronoid fracture, and ulnohumeral dislocation between 2008 and 2023 with at least 10-week follow-up. RESULTS: Nineteen patients were treated post-operatively without HEO, and 22 patients were treated with HEO. There were no differences in range of motion (ROM) between patients treated with and without HEO in final flexion-extension arc (118.4° no HEO, 114.6° HEO, p = 0.59) or pronation-supination arc (147.8° no HEO, 141.4° HEO, p = 0.27). Five patients treated without HEO and one patient treated with HEO returned to the operating room for stiffness (26%, 5%, p = 0.08). QuickDASH scores were similar between groups (p = 0.69). CONCLUSIONS: This study found no difference in post-operative ROM, complications, or QuickDASH scores in patients treated post-operatively with or without HEO. Based on these results, we cannot determine whether the use of HEO adds additional stability to the elbow while initiating ROM exercises post-operatively.

Strengthening the Pipeline: Promoting Diversity into Orthopedic Surgery.

The United States is a nation of diverse racial and ethnic origins. Athletes represent the full spectrum of the nation's population. However, the orthopedic surgeons who serve as team physicians are Caucasian and male with staggeringly few exceptions. This manuscript provides an overview of the current status and barriers to diversity among orthopedic team physicians, along with strategies to address the issue. Specifically, pipeline initiatives implemented at one academic medical school and orthopedic surgery department are summarized as potential models that can be further developed by other institutions to enhance diversity in orthopedic surgery.

Proactive and integrated consultation-liaison psychiatry for older medical inpatients: A mixed methods description of training, care provided and clinician experience in the HOME study.

OBJECTIVES: To describe the practical experience of delivering a proactive and integrated consultation-liaison (C-L) psychiatry service model (PICLP). PICLP is designed for older medical inpatients and is explicitly biopsychosocial and discharge-focused. In this paper we report: (a) observations on the training of 15 clinicians (seven senior C-L psychiatrists and eight assisting clinicians) to deliver PICLP; (b) the care they provided to 1359 patients; (c) their experiences of working in this new way. METHOD: A mixed methods observational study using quantitative and qualitative data, collected prospectively over two years as part of The HOME Study (a randomized trial comparing PICLP with usual care). RESULTS: The clinicians were successfully trained to deliver PICLP according to the service manual. They proactively assessed all patients and found that most had multiple biopsychosocial problems impeding their timely discharge from hospital. They integrated with ward teams to provide a range of interventions aimed at addressing these problems. Delivering PICLP took a modest amount of clinical time, and the clinicians experienced it as both clinically valuable and professionally rewarding. CONCLUSION: The experience of delivering PICLP highlights the special role that C-L psychiatry clinicians, working in a proactive and integrated way, can play in medical care.

Student-Athletes' Deteriorating Mental Health During COVID-19: Recommendations on Proactive Strategies for Addressing Unique Mental Health Needs.

High school and college student-athletes face unique stressors that can negatively impact their mental health, which were exacerbated by the COVID-19 pandemic. Although mental health issues are prevalent in athletic communities, there often remains stigma around mental health and reluctance to seek psychological support. Physical injury can be the cause or the result of the psychological struggles that athletes face-holistic care for the adolescent athlete population must incorporate both elements. Pediatric psychologists, allied healthcare professionals, sports organizations, academic institutions, coaches, caregivers, and student-athletes themselves all play an active role in shaping the mental health of student-athletes and are therefore responsible for creating a culture that prioritizes mental and physical wellness. This paper aims to provide clear recommendations for the various stakeholders on how to address the unique mental health needs of student-athletes. The recommendations presented are based on a review of existing literature in the field and on-the-ground experience working with student-athletes during the COVID-19 pandemic. There are several key interventions highlighted in this paper, including changing the athletic community's culture to prioritize the holistic well-being of athletes, as well as proactively offering mental health education, resources, and programming for student-athletes, with a particular emphasis on health equity to meet the needs of students most at risk. Commitment from pediatric psychologists and allied healthcare professionals, sports organizations, academic institutions, coaches, caregivers, and student-athletes will maximize the likelihood of improving student-athletes' psychological well-being.

Psychological Aspects of Return to Sport for the Female Athlete.

Female athletes represent a unique population of competitors who face distinct stressors when compared with male athletes. These include sport inequities, violence, abuse, body image concerns, disordered eating, relative energy deficiency, family planning challenges, hormonal challenges, and mental distress. When combined with sports injuries, these stressors can negatively impact the mental health of female athletes as well as their injury recovery and return to sports. It is essential for orthopaedic surgeons to be familiar with the unique aspects inherent to being a female athlete, along with the psychological aspects of sports injuries. By integrating questions about female athletes' psychological well-being into their routine practice and collaborating with a multidisciplinary team, orthopaedic surgeons can better address these unique stressors, support female athletes in achieving optimal outcomes, and enhance return to sport rates. Level of Evidence: V, expert opinion.

Effectiveness of psychosocial interventions for pediatric patients with scoliosis: a systematic review.

Background: Pediatric patients affected by scoliosis have complex psychological and social care needs, and may benefit from psychosocial interventions. We therefore aimed to summarize evidence of the efficacy of psychosocial interventions for this patient population. Methods: Literature was identified by searching Medline, PsycINFO, Embase, EBSCO Cumulated Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Central Register of Controlled Trials (CENTRAL) from database inception to 20 March 2022. Articles that evaluated the effectiveness of psychosocial interventions for pediatric patients diagnosed with scoliosis and reported at least one quantitative outcome were included. Article eligibility, data extraction, and quality assessment (using the Cochrane Collaboration's Risk of Bias Tool and Methodological Index for Non-Randomized Studies) were performed by two independent researchers. Findings are presented using narrative synthesis. Results: We identified ten studies, all of which focused on adolescent idiopathic scoliosis. Studies included a total of 1007 participants, most of whom were female. Three studies focused on patients undergoing bracing, six on patients undergoing spinal surgery, and one on patients broadly. Brace compliance monitoring and counseling were found to significantly improve brace compliance quality and quantity. Proactive mental healthcare delivery by nurses after spinal surgery was similarly found to improve outcomes. Several studies examined the efficacy of brief educational interventions; most did not report clear evidence of their efficacy. The methodological quality of studies was often unclear due to limitations in articles' reporting quality. Conclusions: Research on the efficacy of psychosocial interventions for pediatric patients with scoliosis is limited, with interventions involving frequent patient-provider interactions showing the most promise. Future clinical and research efforts should focus on developing and testing psychosocial interventions for this patient population, with emphasis on multidisciplinary teams delivering holistic care. Trial registration number: PROSPERO number CRD42022326957.

Patients Who Return to Sport After Primary Anterior Cruciate Ligament Reconstruction Have Significantly Higher Psychological Readiness: A Systematic Review and Meta-analysis of 3744 Patients.

BACKGROUND: Although objective outcomes assessing knee function are essential measurements for return to sport, psychological factors have become increasingly recognized as equally important parameters for determining an athlete's ability to return to sport after surgery. PURPOSE: To systematically review the literature to determine whether patients who returned to sport after anterior cruciate ligament (ACL) reconstruction had improved psychological scores (as measured with validated questionnaires) compared with patients who did not return to sport. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 3. METHODS: A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and was preregistered on PROSPERO. Four databases were searched for level 1 to 3 studies that compared at least 1 psychological outcome measured by a validated questionnaire for patients who did and did not return to sport after primary ACL reconstruction. The following data were recorded: study and patient characteristics; psychological metrics (ACL-Return to Sport Injury [ACL-RSI] scale, Knee Self-Efficacy Scale [K-SES], and Tampa Scale of Kinesiophobia [TSK/TSK-11]); International Knee Documentation Committee (IKDC) score; and clinical metrics. Study methodological quality was analyzed using the methodological index for non-randomized studies (MINORS), and the mean difference (MD) and 95% CI were calculated for each psychological outcome score using the inverse variance method. RESULTS: We included and analyzed 16 articles (3744 patients; 38.9% female; mean age range, 17-28.7 years; mean MINORS score, 19.9 ± 1.4). Overall, 61.8% of athletes returned to sport (66.8% of male patients; 55.4% of female patients). Patients who returned scored significantly higher on the ACL-RSI scale (MD, 20.8; 95% CI, 15.9 to 25.7; P < .001), significantly higher on the K-SES (MD, 1.3; 95% CI, 0.2 to 2.3; P = .036), and significantly lower on the TSK/TSK-11 (MD, 10.1%; 95% CI, -12.1% to -8.2%; P = .004). Those returning to sport did not exceed the minimal clinically important difference for IKDC score versus those not returning to sport. CONCLUSION: Patients who returned to sport after primary ACL reconstruction had significantly higher psychological readiness, higher self-efficacy, and lower kinesiophobia compared with those who did not return to sport, despite having clinically similar knee function scores. Evaluation of psychological readiness, in combination with other objective measurements, is a critical component of return-to-sport evaluation in athletes after primary ACL reconstruction. REGISTRATION: CRD42021284735 (PROSPERO).

The Prevalence of Psychiatric Disorders in General Hospital Inpatients: A Systematic Umbrella Review.

BACKGROUND: To inform the future development of consultation-liaison psychiatry services, we need accurate information on the prevalence of psychiatric disorders in the general hospital inpatient setting. Systematic reviews have summarized the literature on specific aspects of this broad topic, but there has been no high-level overview that aggregates their findings and identifies gaps in the relevant literature. OBJECTIVE: We aimed to produce a comprehensive overview of the field, summarizing the research literature on the prevalence of psychiatric disorders (i.e., interview-based psychiatric diagnoses) in general hospital inpatients. We did this using a systematic umbrella review (systematic review of systematic reviews), which is the best and most efficient method for summarizing a broad area of research. METHODS: We searched Ovid Medline, Ovid Embase, Ovid PsycINFO, EBSCO CINAHL, and Scopus from database inception to September 2021 for systematic reviews that provided a pooled prevalence estimate, or prevalence range, for interview-diagnosed psychiatric disorders in general hospital inpatients. Two reviewers independently assessed articles and extracted data. The review is registered with PROSPERO, number CRD42019125574. RESULTS: We screened 11,728 articles and included 10 systematic reviews in our umbrella review. We were able to extract pooled prevalence estimates from these as follows: major depression 12% to 20%, any anxiety disorder 8%, generalized anxiety disorder 5%, panic disorder 3%, delirium 15%. We were only able to extract a prevalence range for dementia, which was 3% to 63%. We found no systematic reviews from which we could extract prevalence data for the other psychiatric disorders that we included in our searches, indicating important gaps. From these data, we estimated that approximately one-third of inpatients have a psychiatric disorder. CONCLUSIONS: Psychiatric disorders are very common in general hospital inpatients. While the planning of consultation-liaison psychiatry services will benefit from more research on the prevalence of each of the full range of disorders encountered in the inpatient setting, our findings indicate that we already know enough to justify increased and more population-based service provision.

The prevalence of anxiety in general hospital inpatients: A systematic review and meta-analysis.

OBJECTIVE: To determine the prevalence of anxiety in general hospital inpatients by conducting a systematic review and meta-analysis of all relevant published studies. METHOD: We searched Ovid Medline, Ovid Embase and Ovid PsycINFO from inception to December 2020. We included studies of the prevalence of anxiety symptoms of clinically significant severity (using cut-off scores on rating scales) and of the prevalence of anxiety disorders (using diagnostic interviews) in general hospital inpatients. Two independent reviewers assessed articles and extracted data. The review is registered with PROSPERO, number CRD42020189722. RESULTS: We included 32 studies. Pooled prevalence estimates in random-effects meta-analyses were: anxiety symptoms 28% (95% CI 19% to 38%, 95% prediction interval 5% to 72%), any anxiety disorder 8% (95% CI 5% to 12%, 95% prediction interval 2% to 33%), panic disorder 3% (95% CI 2% to 4%, 95% prediction interval 1% to 8%), generalized anxiety disorder 5% (95% CI 3% to 8%, 95% prediction interval 1% to 23%). There was high heterogeneity in prevalence, little of which was explained in exploratory analyses of a limited number of potential determinants. CONCLUSION: Anxiety symptoms of clinically significant severity affect more than one in four inpatients and anxiety disorders affect nearly one in ten.

'Do not attempt cardiopulmonary resuscitation' (DNACPR)-difficulty in discussions with older medical inpatients and their families: a survey of hospital doctors.

OBJECTIVES: To determine, for doctors looking after older medical inpatients: (1) how difficult they find discussions about 'do not attempt cardiopulmonary resuscitation' (DNACPR); (2) whether difficulty is associated with doctors' personal and professional characteristics; (3) how frequently DNACPR discussions are made more difficult by practical issues and by doctors' uncertainties. METHODS: Survey of hospital doctors working on the acute medical wards of a UK NHS teaching hospital. RESULTS: 171/200 (86%) of eligible doctors participated. 165 had experience of DNACPR discussions with older inpatients and/or their families and were included in our analysis. 'Difficulty' (defined as finding discussions 'fairly difficult' or 'difficult') was experienced by 52/165 (32%) for discussions with patients and 60/165 (36%) for discussions with families. Doctors with specific training in DNACPR discussions were less likely to have difficulty in discussions with patients. Older, more experienced doctors were less likely to have difficulty in discussions with families. Lack of time and place, and uncertainty about prognosis were the most frequently reported causes of difficulty. CONCLUSIONS: Many doctors have difficulty in DNACPR discussions. Training needs to include managing discussions with families, as well as with patients, and doctors need time and space to deliver this important part of their job.

Major Depression and Survival in People With Cancer.

OBJECTIVE: The question of whether depression is associated with worse survival in people with cancer remains unanswered because of methodological criticism of the published research on the topic. We aimed to study the association in a large methodologically robust study. METHODS: We analyzed data on 20,582 patients with breast, colorectal, gynecological, lung, and prostate cancers who had attended cancer outpatient clinics in Scotland, United Kingdom. Patients had completed two-stage screening for major depression as part of their cancer care. These data on depression status were linked to demographic, cancer, and subsequent mortality data from national databases. We estimated the association of major depression with survival for each cancer using Cox regression. We adjusted for potential confounders and interactions between potentially time-varying confounders and the interval between cancer diagnosis and depression screening, and used multiple imputation for missing depression and confounder data. We pooled the cancer-specific results using fixed-effects meta-analysis. RESULTS: Major depression was associated with worse survival for all cancers, with similar adjusted hazard ratios (HRs): breast cancer (HR = 1.42, 95% confidence interval [CI] = 1.15-1.75), colorectal cancer (HR = 1.47, 95% CI = 1.11-1.94), gynecological cancer (HR = 1.36, 95% CI = 1.08-1.71), lung cancer (HR = 1.39, 95% CI = 1.24-1.56), and prostate cancer (HR = 1.76, 95% CI = 1.08-2.85). The pooled HR was 1.41 (95% CI = 1.29-1.54, p < .001, I2 = 0%). These findings were not materially different when we only considered the deaths (90%) that were attributed to cancer. CONCLUSIONS: Major depression is associated with worse survival in patients with common cancers. The mechanisms of this association and the clinical implications require further study.

The effectiveness of inpatient consultation-liaison psychiatry service models: A systematic review of randomized trials.

OBJECTIVE: To systematically review randomized trials of the effectiveness of inpatient Consultation-Liaison (C-L) Psychiatry service models in improving patient outcomes, reducing length of hospital stay and decreasing healthcare costs. METHOD: We searched databases including Ovid Medline, Ovid Embase, Ovid PsycINFO and EBSCO CINAHL for relevant trials. Two independent reviewers assessed articles and extracted data. The review is registered with PROSPERO, number CRD42019120827. RESULTS: Eight trials were eligible for inclusion. All had methodological limitations and all were published more than ten years ago. None reported clear evidence that the C-L Psychiatry service model evaluated was more effective than usual medical care alone. All the service models tested focused on providing a consultation for patients identified by screening. Clinical heterogeneity precluded meta-analysis. CONCLUSION: Whilst we found no evidence that any of the inpatient C-L Psychiatry service models evaluated is effective, the sparseness of the literature and its methodological limitations preclude strong conclusions. The trials do, however, suggest that purely consultation-based service models may not be effective. A new generation of robust clinical trials of a wider range of C-L Psychiatry service models is now required to inform future service developments.

Different independent associations of depression and anxiety with survival in patients with cancer.

OBJECTIVE: Depression and anxiety have both been reported to predict worse subsequent survival in people with cancer. However, depression and anxiety are mutually associated and we lack understanding of their independent associations with survival. We therefore aimed to investigate these in a large sample of patients with common cancers. METHODS: We analysed data on 19,966 patients with common cancers (breast, colorectal, gynaecological, lung and prostate) who had attended specialist NHS outpatient clinics in Scotland, UK. Hospital Anxiety and Depression Scale (HADS) data were linked with demographic, cancer and mortality data. We estimated the independent associations of depression (HADS depression score) and anxiety (HADS anxiety score) with survival by fitting (separately for each cancer) Cox proportional hazards models which incorporated cubic splines to allow for non-linear associations. We also adjusted for potential confounders. RESULTS: The median time from HADS completion to death or censoring was 1.9 years. Greater depression was found to be strongly associated with worse survival from all cancers. When adjusted for anxiety, this association remained in males and increased in females. Greater anxiety was also associated with worse survival in nearly all cancers. However, when adjusted for depression, the association of anxiety with worse survival was lost. In females the association reversed direction so that greater anxiety was associated with better survival. CONCLUSION: Although often considered together as aspects of 'emotional distress', depression and anxiety have different independent associations with survival in patients with cancer and should therefore be considered separately.

The HOME Study: Statistical and economic analysis plan for a randomised controlled trial comparing the addition of Proactive Psychological Medicine to usual care, with usual care alone, on the time spent in hospital by older acute hospital inpatients.

BACKGROUND: Prolonged acute hospital stays are a problem for older people and for health services. Failure to effectively manage the psychological and social aspects of illness is an important cause of prolonged hospital stay. Proactive Psychological Medicine (PPM) is a new way of providing psychiatry services to medical wards which is proactive, focussed, intensive and integrated with medical care. The primary aim of PPM is to reduce the time older people spend in hospital because of unmanaged psychological and social problems. The HOME Study will test the effectiveness and cost-effectiveness of PPM. METHODS/DESIGN: The study is a two-arm, parallel-group, randomised, controlled superiority trial with linked health economic analysis and an embedded process evaluation. The target population is people aged 65 years and older admitted to acute hospitals. Participants will be randomly allocated to either usual care plus PPM or usual care alone. The primary outcome is the number of days spent as an inpatient in a general hospital in the month following randomisation. Secondary outcomes include quality of life, cognitive function, independent functioning, symptoms of anxiety and depression, and experience of hospital stay. The cost-effectiveness of usual care plus PPM compared with usual care alone will be assessed using quality-adjusted life-years as an outcome as well as costs from the NHS perspective. DISCUSSION: This update to the published trial protocol gives a detailed plan of the statistical and economic analysis of The HOME Study. TRIAL REGISTRATION: ISRCTN registry, ISRCTN86120296. Registered on 3 January 2018.

The HOME Study: study protocol for a randomised controlled trial comparing the addition of Proactive Psychological Medicine to usual care, with usual care alone, on the time spent in hospital by older acute hospital inpatients.

BACKGROUND: Prolonged acute hospital stays are a major problem for older people and for health services. Failure to effectively manage the psychological and social aspects of illness is an important cause of prolonged hospital stays. Proactive Psychological Medicine (PPM) is a new way of providing psychiatry services to medical wards. PPM is proactive, focussed, intensive and integrated with medical care. A major aim of PPM is to reduce the time older people spend in hospital because of unmanaged psychological and social problems. The HOME Study will test the effectiveness and cost-effectiveness of PPM. METHODS/DESIGN: A two-arm parallel-group randomised controlled superiority trial, with a linked health economic analysis and an embedded process evaluation, will be conducted at three sites. A total of 3588 participants will be recruited and randomised to usual care or usual care plus PPM. The primary outcome is the number of days spent as an inpatient in a general hospital in the month (30 days) post-randomisation. Secondary outcomes for each participant (measured at 1 and 3 months) include quality of life, independent functioning, symptoms of anxiety and depression, cognitive function, and their experience of the hospital stay. DISCUSSION: The trial has been designed to produce findings that are generalisable to all older medical inpatients (including those with cognitive impairment). It will provide information on the effectiveness and cost-effectiveness of PPM, which we hope will be of value to patients, clinicians, managers and service planners. TRIAL REGISTRATION: ISRCTN86120296 . Registered on 3 January 2018.