Updates in Consultation-Liaison Psychiatry: 2019.

BACKGROUND: The scientific literature in consultation-liaison psychiatry continually expands, and remaining familiar with the most current literature is challenging for practicing clinicians. The Guidelines and Evidence-Based Medicine Subcommittee of the Academy of Consultation-Liaison Psychiatry writes quarterly annotations of articles of interest to help Academy members gain familiarity with the most current evidence-based practices. These annotations are available on the Academy Website. OBJECTIVE: We identify the 10 most important manuscripts for clinical practice in consultation-liaison psychiatry from 2019. METHODS: Sixty-four abstracts were authored in 2019. Manuscripts were rated on clinical relevance to practice and quality of scholarship. The 10 articles with the highest aggregate scores from 19 raters are described. RESULTS: The resulting articles provide practical guidance for consultation psychiatrists on several topic areas including the treatment of substance use disorders. CONCLUSION: We suggest that these clinical findings should be familiar to all consultation-liaison psychiatrists regardless of practice area. Regular article reviews and summaries help busy clinicians deliver cutting-edge care and maintain a high standard of care across the specialty.

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.

Updates in Psychosomatic Medicine: 2014.

BACKGROUND: The amount of literature published annually related to psychosomatic medicine is vast; this poses a challenge for practitioners to keep up-to-date in all but a small area of expertise. OBJECTIVES: To introduce how a group process using volunteer experts can be harnessed to provide clinicians with a manageable selection of important publications in psychosomatic medicine, organized by specialty area, for 2014. METHODS: We used quarterly annotated abstracts selected by experts from the Academy of Psychosomatic Medicine and the European Association of Psychosomatic Medicine in 15 subspecialties to create a list of important articles. RESULTS: In 2014, subspecialty experts selected 88 articles of interest for practitioners of psychosomatic medicine. For this review, 14 articles were chosen. CONCLUSIONS: A group process can be used to whittle down the vast literature in psychosomatic medicine and compile a list of important articles for individual practitioners. Such an approach is consistent with the idea of physicians as lifelong learners and educators.

Caring for persons with early childhood trauma, PTSD, and HIV: a curriculum for clinicians.

Access and adherence to medical care enable persons with HIV to live longer and healthier lives. Adherence to care improves quality of life, prevents progression to AIDS, and also has significant public health implications. Early childhood trauma-induced posttraumatic stress disorder (PTSD) is one factor that has been identified as an obstacle to adherence to both risk reduction and HIV care. The authors developed a 4-h curriculum to provide clinicians with more confidence in their ability to elicit a trauma history, diagnose PTSD, and address trauma and its sequelae in persons with HIV to improve adherence to medical care, antiretroviral medications, and risk reduction. The curriculum was designed to address the educational needs of primary care physicians, infectious disease specialists, psychiatrists, other specialists, psychologists, social workers, nurses, residents, medical students, and other trainees who provide care for persons infected with and affected by HIV.

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.

Burnout and Moral Injury Among Consultation-Liaison Psychiatry Trainees.

Burnout and moral injury within medicine have steadily increased over the last decades, especially among those providing care during the COVID-19 pandemic. The term burnout has been used to describe clinician distress and a syndrome of emotional exhaustion, a diminished sense of personal accomplishment, and depersonalization. Burnout has a significant impact on both job performance and patient care. Moral injury occurs when external circumstances interact with a person's cherished beliefs and standards. When the tension between them cannot be reconciled, the felt integrity of the individual is disrupted and the person experiences distress. The consultative aspect in consultation-liaison psychiatry (CLP) presents challenges that may predispose the young clinician to burnout and moral injury, especially during fellowship training. CLP psychiatrists also have a liaison role that could catalyze systemlevel change to enhance the mental well-being of their colleagues. This article reviews clinically relevant psychodynamic aspects of burnout and moral injury during CLP training. In addition, the authors propose strategies to enhance career growth and prevent and address moral injury during training to generate fulfilling professional development.

Identifying the Most Important Consultation-Liaison Psychiatry Publications in 2020 Using a Novel Literature Assessment Instrument.

BACKGROUND: As the science of consultation-liaison psychiatry advances, the Academy of Consultation-Liaison Psychiatry's Guidelines and Evidence-Based Medicine Subcommittee reviews articles of interest to help academy members remain familiar with the latest in evidence-based practice. OBJECTIVE: We identify the 10 most important articles for clinical practice in consultation-liaison psychiatry from 2020 using the new Importance and Quality instrument for assessing scientific literature. METHODS: The subcommittee published annotated abstracts for 97 articles on the academy website in 2020. Reviewers then rated all articles on clinical importance to practice and quality of scholarship using the Importance and Quality instrument. We describe the 10 articles with the highest aggregate scores and analyze the reliability of Importance and Quality instrument. RESULTS: Twenty-four raters identified the top 10 scoring articles of 2020. These articles provide practical guidance on key areas of consultation-liaison psychiatry including management of COVID-19, lithium treatment for complex patients, medical risks among patients with severe mental illness, and substance use disorders in medical settings. The assessment instrument demonstrated good to excellent interrater reliability. CONCLUSION: These articles offer valuable guidance for consultation-liaison psychiatrists regardless of their practice area. Collaborative literature reviews with standardized assessments help clinicians deliver evidence-based care and foster a high standard of practice across the specialty.

Psychiatric treatment of persons with HIV/AIDS: an HIV-psychiatry consensus survey of current practices.

BACKGROUND: Only sparse evidence from controlled clinical trials is available to guide the psychiatric treatment of persons with HIV/AIDS. OBJECTIVE: The authors assessed and determined current treatment trends in AIDS psychiatry. METHOD: Members of the Organization of AIDS Psychiatry (OAP) participated in a web-based survey. RESULTS: Of 159 members, 62 (39%) responded to the survey. Consensus emerged regarding first-line treatment for depression (escitalopram/citalopram), for psychosis and secondary mania (quetiapine), and for anxiety (clonazepam). CONCLUSION: Consensus statements can serve as a preliminary step toward providing some standardization of care for persons with HIV/AIDS.

Impact of bereavement on progression of AIDS and HIV infection: a review.

BACKGROUND: Human immunodeficiency virus (HIV) disease is associated with bereavement and grief reactions brought about by the disease process itself and by the losses of loved ones. OBJECTIVE: The goal of this review is to assess the current literature regarding grief, HIV, and immunity. METHOD: The authors reviewed applicable articles retrieved from a MEDLINE literature search with the search terms "bereavement/HIV," "grief/HIV," and "immunity/grief/HIV." RESULTS: Data continue to emerge that suggest a profound role for bereavement in mediating HIV illness and the need to effectively deal with bereavement issues. CONCLUSIONS: Patients who experience maladaptive grief show more rapid losses of CD4 T-cells over time, even when controlling for age, health status, use of antiretrovirals, and illicit drug abuse. This immune dysfunction may be managed by a variety of psychotherapeutic techniques.

Preserving a sense of wonder: the integration of an ego-supportive psychodynamic approach to supervision in an AIDS psychiatry fellowship.

The challenges of working with medically and mentally ill persons with a paucity of resources, inadequate networks of social support, and multiple stresses and losses maybe daunting to even the most seasoned of caregivers. A psychiatric trainee may be overwhelmed by the despair, sorrow, and desperation en-countered in the day-to-day care of the complex severely ill patient with lethalmedical and lethal psychiatric diagnoses. Individuals who are infected with HIV and hepatitis C, who are polysubstance users, and who are benzodiazepine dependent present with inordinate demands for prescribed substances to use or to sell in the street. The trainee needs to become comfortable with both limit-setting and harm reduction in order to keep the patient engaged in both lifesaving medical and psychiatric care. Nurturing and supportive supervision enables the trainee to integrate skills and work toward an understanding of countertransferences. An ego-supportive psychodynamic approach to supervision in an AIDS psychiatry fellowship facilitates conflict resolution and improves the care of patients with complex and severe medical illness.

Understanding the psychodynamics of non-adherence to medical treatment in persons with HIV infection.

We present this medical-psychiatric case discussion to illustrate the psychodynamic aspects of nonadherence in a woman with AIDS. Our patient sustained severe, repeated abandonment and brutal emotional, physical and sexual trauma throughout her early and later childhood and adult life. Her care was considerably complicated by the sequelae of trauma including difficulty with trust and posttraumatic stress disorder. The additional problem of HIV dementia compounded the patient's nonadherence to treatment. We present a multidisciplinary biopsychosocial approach that enabled the patient to engage in both medical and psychiatric care.

Early childhood trauma, posttraumatic stress disorder, and non-adherence in persons with AIDS: a psychodynamic perspective.

Non-adherence to treatment and risk-reduction measures not only leads to increased morbidity and mortality in patients with HIV/AIDS but is also a major public health hazard. While there are multiple determinants of non-adherence, one that is particularly complex and refractory to intervention appears to be the history of childhood trauma and the development of post-traumatic stress disorder (PTSD). While behavioral intervention is occasionally helpful in increasing a patient's commitment to self-care, it is our view that the use of a more psychoanalytic framework, as well as the development of a psychodynamic understanding of the patient's history and struggles, may provide both patient and clinician with a more profound understanding of the forces that perpetuate non-adherence, thus facilitating a more cohesive and empathic approach to treatment. It is the aim of this article to explore, from a psychodynamic perspective, the possible connections between early childhood trauma resulting in PTSD and non-adherence to risk reduction and HIV treatment.

DNR versus DNT: clinical implications of a conceptual ambiguity: a case analysis.

Psychiatrists who practice psychosomatic medicine are routinely called upon to help resolve ethical dilemmas that arise in the care of patients near the end of their lives. Psychosomatic-medicine psychiatrists may be of unique value in these situations because of the clinical insights that we bring to the care of the dying patient. In particular, our subspecialty brings expertise related to the evaluation of decisional capacity of patients who are faced with accepting or declining end-of-life clinical interventions, such as resuscitation and intubation. In this first entry in a new bioethics case series in Psychosomatics, we will lay the groundwork for examining a complex patient case and provide an illustrative analysis of the end-of-life care issues that may be addressed by psychiatrists who practice psychosomatic medicine.

Consultation-liaison psychiatrists on bioethics committees: opportunities for academic leadership.

OBJECTIVE: This article briefly reviews the history of the relationship between psychiatry and the leadership of ethics committees as a background for examining appropriate educational initiatives to adequately prepare residents and early career psychiatrists to serve as leaders of ethics committees. METHOD: A Medline review of literature on psychiatry and ethics committees and consultation as well as recent survey data from the Academy of Psychosomatic Medicine indicate that psychosomatic medicine psychiatrists are particularly qualified and interested in serving as chairs of ethics committees. The authors compare knowledge and skills obtained in psychiatric training with the Society for Heath and Human Values and the Society for Bioethics Consultation Task Force on standards for ethics consultation proposed as core competencies for ethics committee leadership. RESULTS: Psychiatric residency and fellowship training in psychosomatic medicine can provide the knowledge and skill sets to meet the standards for ethics consultation. Further professional development through pursuit of formal ethics training, advance degrees in bioethics, mentoring, and residency and felloships focus on ethics and enhance competency, confidence, and the skills required for ethics committee leadership. CONCLUSIONS: Academic psychiatrists, particularly those in psychosomatic medicine, have historically made a significant contribution as chairs of ethics committees. Continuation and expansion of this leadership may require interested psychiatrists to obtain additional training in bioethics.

The role of psychosomatic-medicine psychiatrists in bioethics: a survey study of members of the academy of psychosomatic medicine.

The Bioethics Subcommittee of The Academy of Psychosomatic Medicine developed a survey to assess the involvement of psychosomatic-medicine psychiatrists in bioethics and the extent of their participation on bioethics committees and in the teaching of bioethics. Of 599 Academy members surveyed, 122 (20.4%) responded. The majority of respondents reported that the management of bioethical dilemmas had a significant impact on their work in psychosomatic medicine. Many respondents were involved in teaching bioethics and in serving on ethics committees. The majority of respondents reported psychiatry-resident involvement on ethics committees. Bioethics work is an integral part of the fabric of psychosomatic medicine.