Neuropsychiatric symptoms in Systemic Lupus Erythematosus: mixed methods analysis of patient-derived attributional evidence in the international INSPIRE project.

OBJECTIVE: Attribution of neuropsychiatric symptoms in systemic lupus erythematosus (SLE) relies heavily on clinician assessment. Limited clinic time, variable knowledge, and symptom under-reporting contributes to discordance between clinician assessments and patient symptoms. We obtained attributional data directly from patients and clinicians in order to estimate and compare potential levels of direct attribution to SLE of multiple neuropsychiatric symptoms using different patient-derived measures. METHODS: Quantitative and qualitative data analysed included: prevalence and frequency of neuropsychiatric symptoms, response to corticosteroids, and concurrence of neuropsychiatric symptoms with non-neuropsychiatric SLE disease activity. SLE patients were also compared with controls and inflammatory arthritis (IA) patients to explore attributability of neuropsychiatric symptoms to the direct disease effects on the brain/nervous system. RESULTS: We recruited 2,817 participants, including 400 clinicians. SLE patients (n = 609) reported significantly higher prevalences of neuropsychiatric symptoms than controls (n = 463) and IA patients (n = 489). SLE and IA patients' quantitative data demonstrated multiple neuropsychiatric symptoms relapsing/remitting with other disease symptoms such as joint pain. Over 45% of SLE patients reported resolution/improvement of fatigue, positive sensory symptoms, severe headache, and cognitive dysfunction with corticosteroids. Evidence of direct attributability in SLE was highest for hallucinations and severe headache. SLE patients had greater reported improvement from corticosteroids (p= 0.008), and greater relapsing-remitting with disease activity (p< 0.001) in the comparisons with IA patients for severe headache. Clinician and patients reported insufficient time to discuss patient-reported attributional evidence. Symptoms viewed as indirectly related/non-attributable were often less prioritised for discussion and treatment. CONCLUSION: We found evidence indicating varying levels of direct attributability of both common and previously unexplored neuropsychiatric symptoms in SLE patients, with hallucinations and severe headache assessed as the most directly attributable. There may also be-currently under-estimated-direct effects on the nervous system in IA and other systemic rheumatological diseases.

Symptom Clusters Seen in Adult COVID-19 Recovery Clinic Care Seekers.

BACKGROUND: COVID-19 symptom reports describe varying levels of disease severity with differing periods of recovery and symptom trajectories. Thus, there are a multitude of disease and symptom characteristics clinicians must navigate and interpret to guide care. OBJECTIVE: To find natural groups of patients with similar constellations of post-acute sequelae of COVID-19 (PASC) symptoms. DESIGN: Cohort SETTING: Outpatient COVID-19 recovery clinic with patient referrals from 160 primary care clinics serving 36 counties in Texas. PATIENTS: Adult patients seeking COVID-19 recovery clinic care between November 15, 2020, and July 31, 2021, with laboratory-confirmed mild (not hospitalized), moderate (hospitalized), or severe (hospitalized with critical care) COVID-19. MAIN MEASURES: Demographics, COVID illness onset, and duration of persistent PASC symptoms via semi-structured medical assessments. KEY RESULTS: Four hundred forty-one patients (mean age 51.5 years; 295 [66.9%] women; 99 [22%] Hispanic, and 170 [38.5%] non-White, racial minority) met inclusion criteria. Using a k-medoids algorithm, we found that PASC symptoms cluster into two distinct groups: neuropsychiatric (N = 186) (e.g., subjective cognitive dysfunction) and pulmonary (N = 255) (e.g., dyspnea, cough). The neuropsychiatric cluster had significantly higher incidences of otolaryngologic (X2 = 14.3, p < 0.001), gastrointestinal (X2 = 6.90, p = 0.009), neurologic (X2 = 441, p < 0.001), and psychiatric sequelae (X2 = 40.6, p < 0.001) with more female (X2 = 5.44, p = 0.020) and younger age (t = 2.39, p = 0.017) patients experiencing longer durations of PASC symptoms before seeking care (t = 2.44, p = 0.015). Patients in the pulmonary cluster were more often hospitalized for COVID-19 (X2 = 3.98, p = 0.046) and had significantly higher comorbidity burden (U = 20800, p = 0.019) and pulmonary sequelae (X2 = 13.2, p < 0.001). CONCLUSIONS: Health services clinic data from a large integrated health system offers insights into the post-COVID symptoms associated with care seeking for sequelae that are not adequately managed by usual care pathways (self-management and primary care clinic visits). These findings can inform machine learning algorithms, primary care management, and selection of patients for earlier COVID-19 recovery referral. TRIAL REGISTRATION: N/A.

Functional deficits and other psychiatric associations with abnormal scores on the Montreal Cognitive Assessment (MoCA) in older HIV-infected patients.

OBJECTIVE: The authors assessed the association of physical function, social variables, functional status, and psychiatric co-morbidity with cognitive function among older HIV-infected adults. DESIGN: From 2012-2014, a cross-sectional study was conducted among HIV-infected patients ages 50 or older who underwent comprehensive clinical geriatric assessment. SETTING: Two San Francisco HIV clinics. PARTICIPANTS: 359 HIV-infected patients age 50 years or older. MEASUREMENTS: Unadjusted and adjusted Poisson regression measured prevalence ratios and 95% confidence intervals for demographic, functional and psychiatric variables and their association with cognitive impairment using a Montreal Cognitive Assessment (MoCA) score < 26 as reflective of cognitive impairment. RESULTS: Thirty-four percent of participants had a MoCA score of < 26. In unadjusted analyses, the following variables were significantly associated with an abnormal MoCA score: born female, not identifying as homosexual, non-white race, high school or less educational attainment, annual income < $10,000, tobacco use, slower gait speed, reported problems with balance, and poor social support. In subsequent adjusted analysis, the following variables were significantly associated with an abnormal MoCA score: not identifying as homosexual, non-white race, longer 4-meter walk time, and poor social support. Psychiatric symptoms of depressive, anxiety, and post-traumatic stress disorders did not correlate with abnormal MoCA scores. CONCLUSIONS: Cognitive impairment remains common in older HIV-infected patients. Counter to expectations, co-morbid psychiatric symptoms were not associated with cognitive impairment, suggesting that cognitive impairment in this sample may be due to neurocognitive disorders, not due to other psychiatric illness. The other conditions associated with cognitive impairment in this sample may warrant separate clinical and social interventions to optimize patient outcomes.

Physician-Assisted Death Psychiatric Assessment: A Standardized Protocol to Conform to the California End of Life Option Act.

BACKGROUND: The California End of Life Option Act (EOLOA), which legalized physician-assisted death (PAD), became effective in 2016. The EOLOA does not require a mental health consultation in all cases nor does it state the standards for the mental health assessment. University of California, San Francisco Medical Center (UCSFMC) policy makers decided to require a mental health assessment of all patients seeking PAD under the EOLOA. OBJECTIVES: The Department of Psychiatry was tasked with developing a standard protocol for the mental health assessment of patients seeking PAD. METHODS: Members of the consultation-liaison (C-L) service developed a document to guide members in completing the mental health evaluations for patients requesting PAD. RESULTS: A committee at UCSFMC developed a clinical protocol informed by the law with an additional local expectation of an evaluation by a psychiatrist or clinical psychologist. The C-L psychiatry group at UCSF developed a standard protocol for the psychiatric assessment for use by clinicians performing these assessments. Attention to the cognitive, mood, and decisional capacity status pertinent to choosing PAD is required under the clinical guidance document. Case vignettes of 6 patients evaluated for PAD are presented. CONCLUSIONS: The local adoption of the California EOLOA by UCSFMC requires a mental health assessment of all patients requesting EOL services at UCSF. The clinical guideline for these assessments was locally developed, informed by the literature on EOL in other jurisdictions where it has already been available.

Decisional and Dispositional Capacity Determinations: Neuropsychiatric Illness and an Integrated Clinical Paradigm.

BACKGROUND: Assessment of decisional capacity requires thorough clinical review of a patient's current psychiatric symptoms and cognitive processes. The assessment to determine the patient's capacity for self-management postdischarge is a different clinical concept from decisional capacity. OBJECTIVES: Standardized guidelines for capacity determinations (both for informed consent and for disposition) would be helpful to clinicians, patients, and their caregivers. METHOD: The authors reviewed the recent clinical literature on neuropsychiatric illnesses associated with impaired decisional capacity, as well as for the term "dispositional capacity." RESULTS: Neurocognitive disorders and neurologic disorders are commonly associated with impaired decisional capacity; other psychiatric illnesses are less commonly associated. There were no articles identified that used the term "dispositional capacity" to describe a subtype of decisional capacity determination. No definition or guidelines for determination of dispositional capacity were found. CONCLUSIONS: Routine evaluation for neurocognitive disorders including standardized cognitive assessment should be included in decisional capacity determinations. There is a need for a new subtype of decisional capacity determination, for which we propose the term "dispositional capacity." This concept is introduced and defined. For dispositional capacity determinations, supplementation of the usual decisional capacity evaluation with in vivo demonstration of self-management skills is recommended. Decisional and dispositional capacity determination is conceptualized with a biopsychosociocultural approach and guidelines for standardized assessment are presented.

Validation of a Nurse-Based Delirium-Screening Tool for Hospitalized Patients.

BACKGROUND: Guidelines recommend daily delirium monitoring of hospitalized patients. Available delirium-screening tools have not been validated for use by nurses among diverse inpatients. OBJECTIVE: We sought to validate the Nursing Delirium-Screening Scale (Nu-DESC) under these circumstances. METHODS: A blinded cross-sectional and quality-improvement study was conducted from August 2015-February 2016. Nurses׳ Nu-DESC scores were compared to delirium diagnosis according to Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) criteria. A total of 405 consecutive hospitalized patients were included. Nu-DESC-positive (threshold score ≥2) patients were matched with equal numbers of Nu-DESC-negative patients, by sex, age, and nursing unit. Nurses recorded a Nu-DESC score for each patient on every 12-hour shift. A Nu-DESC-blinded evaluator interviewed patients for 2 consecutive days. Delirium diagnosis was determined by physicians using DSM-5 criteria applied to collected research data. Sensitivity and specificity of the Nu-DESC were calculated. In an exploratory analysis, the performance of the Nu-DESC was analyzed with the addition of bedside measures of attention. RESULTS: The sensitivity of the Nu-DESC at a threshold of ≥2 was 42% (95% CI: 33-53%). Specificity was 98% (97-98%). At a threshold of ≥1, sensitivity was 67% (52-80%) and specificity 93% (90-95%). Similar results were found with the addition of attention tasks. CONCLUSION: The Nu-DESC is a specific delirium detection tool, but it is not sensitive at the usually proposed cut point of ≥2. Using a threshold of ≥1 or adding a test of attention increase sensitivity with a minor decrease in specificity.

Geriatric gambling disorder: challenges in clinical assessment.

To the Editor: The gaming industry is growing rapidly, as is the proportion of older adults aged 65 years or older who participate in gambling (Tse et al., 2012). With casinos tailoring their venues and providing incentives to attract older adults, and with the increasing popularity of "pleasure trips" to casinos organized by retirement homes, plus active promotion of government-operated lotteries in many countries, this trend is likely to continue. Gambling disorder (GD) or "pathological" or "problem" gambling presents a public health concern in the geriatric population. However, ascertainment of its prevalence and diagnostic accuracy have proven challenging. This is largely due to the absence of diagnostic criteria specific to the geriatric age and rating scales validated for use in this population.

Aging with autism spectrum disorder: an emerging public health problem.

From 1943, when Leo Kanner originally described autism, and to the first objective criteria for "infantile autism" in DSM-III and the inclusion of Asperger's disorder in DSM-IV, the subsequent classification scheme for autistic disorders has led to a substantial change with the 2013 issuance of the DSM-5 by including subcategories into one umbrella diagnosis of autism spectrum disorder (ASD) (Baker, 2013). ASD is a lifelong neurodevelopmental disorder, characterized by social and communication impairments and restricted, stereotypical patterns of behavior (Baker, 2013). It is currently expected that most, or all of the actual cases of ASD, are identified in a timely way (i.e. in early childhood). However, there are many undiagnosed older adults who may have met the current diagnostic criteria for ASD as children, but never received such a diagnosis due to the fact it had yet to be established. In addition, some patients with relatively less impairing phenotypes may escape formal diagnosis in childhood, only to later be diagnosed in adulthood. Nevertheless, the first generation of diagnosed patients with ASD is now in old age. Many such ASD patients have needed family and institutional support for their lives subsequent to childhood diagnosis. Due to aging and death of their parents and other supportive figures leading to a loss of social structures, there is no better time than now for the medical community to act.

Academics anonymous: A medical student's 12-step guide to scholarly productivity.

An important aspect of academic medicine is publication in peer-reviewed journals and other media. Early scholarly productivity in medical school may jump-start a successful academic career. Topic choice, search methodology, writing strategies, mentorship, and collaboration are all fundamental to successful academic productivity. The authors reviewed the importance of instituting the germinal stages of scholarly productivity during medical training and created 12 steps for facilitating productive academic writing by students.

Number of patient-reported allergies helps distinguish epilepsy from psychogenic nonepileptic seizures.

Psychogenic nonepileptic seizures (PNES) are relatively common, accounting for 5-40% of visits to tertiary epilepsy centers. Inpatient video-electroencephalogram (vEEG) monitoring is the gold standard for diagnosis, but additional positive predictive tools are necessary given vEEG's relatively scarce availability. In this study, we investigated if the number of patient-reported allergies distinguishes between PNES and epilepsy. Excessive allergy-reporting, like PNES, may reflect somatization. Using electronic medical records, ICD-9 codes, and text-identification algorithms to search EEG reports, we identified 905 cases of confirmed PNES and 5187 controls with epilepsy but no PNES. Patients with PNES averaged more self-reported allergies than patients with epilepsy alone (1.93 vs. 1.00, p<0.001). Compared to those with no allergies, each additional allergy linearly increased the percentage of patients with PNES by 2.98% (R(2)=0.71) such that with ≥12 allergies, 12/28 patients (42.8%) had PNES compared to 349/3368 (11.6%) of the population with no allergies (odds ratio=6.49). This relationship remained unchanged with logistic regression analysis. We conclude that long allergy lists may help identify patients with PNES. We hypothesize that a tendency to inaccurately self-report allergies reflects a maladaptive externalization of psychologic distress and that a similar mechanism may be responsible for PNES in some patients with somatic symptom disorder.

Telepsychiatry for Inpatient Consultations at a Separate Campus of an Academic Medical Center.

BACKGROUND: Many hospitals do not have regular access to psychiatry consult services. This is well understood as a common shortage at nonacademic community hospitals (especially in rural environments, and may also be a problem at noncontiguously located smaller hospitals that are affiliated with academic medical centers in urban settings. The authors sought to deliver timely inpatient psychiatric consultation-liaison services via telemedicine to a local but physically separated hospital affiliated with an academic medical center. MATERIALS AND METHODS: The authors collaborated with an office dedicated to the advancement of telemedicine technology at their academic medical center. They developed a telemedicine-based care model to deliver inpatient consultation-liaison psychiatry consultations to an affiliated (but physically separate) small academic hospital that did not have its own on-site consultation-liaison psychiatry team. RESULTS: The authors were able to successfully complete 30 consultations, each within 24 h. Only 1 patient was ultimately unwilling to participate in the telemedicine interview. As consultations were accomplished on same day as request, patient length of stay was unaffected. CONCLUSIONS: This pilot study suggests that telemedicine is a viable model for inpatient consultation-liaison psychiatry services to hospitals without on-site psychiatry resources and represents a viable alternative model of service delivery.

Delirium and hypovitaminosis D: neuroimaging findings.

The authors examined the frequency of neuroimaging findings of cortical atrophy and/or cerebrovascular disease in patients with delirium with hypovitaminosis D and normal vitamin D levels. Of 32 patients with delirium with hypovitaminosis D who were neuroimaged, 91.4% had neuroimaging findings, despite only five cases having a comorbid diagnosis of dementia. Similar frequencies of cortical atrophy and/or cerebrovascular disease were found in patients with delirium with normal vitamin D levels. Further research with a larger sample size is needed to compare neuroimaging findings between normal patients and patients with hypovitaminosis D with delirium.

The medical-psychiatric coordinating physician-led model: team-based treatment for complex patients.

OBJECTIVE: We propose a patient care model involving psychiatrist-led multispecialty teams for treatment of the most treatment-refractory segment of "complex" outpatients. We call the psychiatrist taking this leadership role the Medical-Psychiatric Coordinating Physician. METHOD: The authors conducted a pilot study for this treatment model with 52 office-based outpatient cases each involving complex patients, and each with at least 2 major treatment failures. They followed these patients empirically for at least 18 months. Outcomes examined included Hamilton Anxiety Rating Scale; Hamilton Depression Rating Scale; and Health Related Quality of Life-14 scores (HRQOL-14, modified), in association with a comprehensive treatment review. RESULTS: Comprehensive treatment review indicated sustained improvement in at least 2 of 4 clinical dimensions (utilization, treatment adherence, symptomatology, and quality of life) in 44 of 52 patients. Included were Hamilton Anxiety Rating Scale scores that improved significantly from 26.27 ± 7.5 to 18.13 ± 5.74 (p < 0.0001) and Hamilton Depression Rating Scale scores that improved from 22.02 ± 7.10 to 14.58 ± 6.46 (p < 0.0001). The Health-Related Quality of Life-14 improved significantly for general health from 2.54 ± 1.03 to 2.12 ± 1.06 (p < 0.0001), and sick days per month from 11.22 ± 7.76 to 6.60 ± 7.51 (p < 0.0001). CONCLUSIONS: The Medical-Psychiatric Coordinating Physician-led multispecialty team method may be advantageous for the ongoing outpatient treatment of management-intensive, complex patients. We offer this model as having a place among the available integrated care models for the treatment of comorbid psychiatric-systemic medical illness.

HIV Psychiatry: The Missing Link to HIV Prevention and Comprehensive Care.

HIV psychiatry may be the missing link to HIV prevention and care. Although HIV has been transformed from a fatal illness to a chronic and manageable illness, morbidity and mortality from HIV and AIDS continue to persist despite advances in prevention and care. In the 42 years since the HIV pandemic began in 1981, >84 million people were infected with HIV and 40 million people with HIV have died. In 2021, 1.5 million were newly infected and as of 2022, >38 million people were living with HIV.