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.

Mortality and major disease risk among migrants of the 1991-2001 Balkan wars to Sweden: A register-based cohort study.

BACKGROUND: In recent decades, millions of refugees and migrants have fled wars and sought asylum in Europe. The aim of this study was to quantify the risk of mortality and major diseases among migrants during the 1991-2001 Balkan wars to Sweden in comparison to other European migrants to Sweden during the same period. METHODS AND FINDINGS: We conducted a register-based cohort study of 104,770 migrants to Sweden from the former Yugoslavia during the Balkan wars and 147,430 migrants to Sweden from 24 other European countries during the same period (1991-2001). Inpatient and specialized outpatient diagnoses of cardiovascular disease (CVD), cancer, and psychiatric disorders were obtained from the Swedish National Patient Register and the Swedish Cancer Register, and mortality data from the Swedish Cause of Death Register. Adjusting for individual-level data on sociodemographic characteristics and emigration country smoking prevalence, we used Cox regressions to contrast risks of health outcomes for migrants of the Balkan wars and other European migrants. During an average of 12.26 years of follow-up, being a migrant of the Balkan wars was associated with an elevated risk of being diagnosed with CVD (HR 1.39, 95% CI 1.34-1.43, p < 0.001) and dying from CVD (HR 1.45, 95% CI 1.29-1.62, p < 0.001), as well as being diagnosed with cancer (HR 1.16, 95% CI 1.08-1.24, p < 0.001) and dying from cancer (HR 1.27, 95% CI 1.15-1.41, p < 0.001), compared to other European migrants. Being a migrant of the Balkan wars was also associated with a greater overall risk of being diagnosed with a psychiatric disorder (HR 1.19, 95% CI 1.14-1.23, p < 0.001), particularly post-traumatic stress disorder (HR 9.33, 95% CI 7.96-10.94, p < 0.001), while being associated with a reduced risk of suicide (HR 0.68, 95% CI 0.48-0.96, p = 0.030) and suicide attempt (HR 0.57, 95% CI 0.51-0.65, p < 0.001). Later time period of migration and not having any first-degree relatives in Sweden at the time of immigration were associated with greater increases in risk of CVD and psychiatric disorders. Limitations of the study included lack of individual-level information on health status and behaviors of migrants at the time of immigration. CONCLUSIONS: Our findings indicate that migrants of the Balkan wars faced considerably elevated risks of major diseases and mortality in their first decade in Sweden compared to other European migrants. War migrants without family members in Sweden or with more recent immigration may be particularly vulnerable to adverse health outcomes. Results underscore that persons displaced by war are a vulnerable group in need of long-term health surveillance for psychiatric disorders and somatic disease.

The clinical and financial cost of mental disorders among elderly patients with gastrointestinal malignancies.

The clinical and financial effects of mental disorders are largely unknown among gastrointestinal (GI) cancer patients. Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database, we identified patients whose first cancer was a primary colorectal, pancreatic, gastric, hepatic/biliary, esophageal, or anal cancer as well as those with coexisting depression, anxiety, psychotic, or bipolar disorder. Survival, chemotherapy use, total healthcare expenditures, and patient out-of-pocket expenditures were estimated and compared based on the presence of a mental disorder. We identified 112,283 patients, 23,726 (21%) of whom had a coexisting mental disorder. Median survival for patients without a mental disorder was 52 months (95% CI 50-53 months) and for patients with a mental disorder was 43 months (95% CI 42-44 months) (p < 0.001). Subgroup analysis identified patients with colorectal, gastric, or anal cancer to have a significant association between survival and presence of a mental disorder. Chemotherapy use was lower among patients with a mental disorder within regional colorectal cancer (43% vs. 41%, p = 0.01) or distant colorectal cancer subgroups (71% vs. 63%, p < 0.0001). The mean total healthcare expenditures were higher for patients with a mental disorder in first year following the cancer diagnosis (increase of $16,823, 95% CI $15,777-$18,173), and mean patient out-of-pocket expenses were also higher (increase of $1,926, 95% CI $1753-$2091). There are a substantial number of GI cancer patients who have a coexisting mental disorder, which is associated with inferior survival, higher healthcare expenditures, and greater personal financial burden.

The early impact of COVID-19 on mental health and community physical health services and their patients' mortality in Cambridgeshire and Peterborough, UK.

BACKGROUND: COVID-19 has affected social interaction and healthcare worldwide. METHODS: We examined changes in presentations and referrals to the primary provider of mental health and community health services in Cambridgeshire and Peterborough, UK (population ~0·86 million), plus service activity and deaths. We conducted interrupted time series analyses with respect to the time of UK "lockdown", which was shortly before the peak of COVID-19 infections in this area. We examined changes in standardized mortality ratio for those with and without severe mental illness (SMI). RESULTS: Referrals and presentations to nearly all mental and physical health services dropped at lockdown, with evidence for changes in both supply (service provision) and demand (help-seeking). This was followed by an increase in demand for some services. This pattern was seen for all major forms of presentation to liaison psychiatry services, except for eating disorders, for which there was no evidence of change. Inpatient numbers fell, but new detentions under the Mental Health Act were unchanged. Many services shifted from face-to-face to remote contacts. Excess mortality was primarily in the over-70s. There was a much greater increase in mortality for patients with SMI, which was not explained by ethnicity. CONCLUSIONS: COVID-19 has been associated with a system-wide drop in the use of mental health services, with some subsequent return in activity. "Supply" changes may have reduced access to mental health services for some. "Demand" changes may reflect a genuine reduction of need or a lack of help-seeking with pent-up demand. There has been a disproportionate increase in death among those with SMI during the pandemic.

Association of Specific Mental Disorders With Premature Mortality in the Danish Population Using Alternative Measurement Methods.

Importance: The association of mental disorders with premature mortality published in the Global Burden of Disease (GBD) studies has been underestimated because these analyses have recommended using only a small number of mental disorders as causes of death to estimate years of life lost (YLL). Alternative methods have been introduced, such as estimating life-years lost (LYL), to compare individuals with mental disorders with the general population. Objectives: To generate register-based YLL and LYL estimates and to use these measurement methods to assess the association of specific mental disorders with premature mortality. Design, Setting, and Participants: This population-based cohort study included all persons with and without mental disorders aged 0 to 94 years who were living in Denmark between January 1, 2000, and December 31, 2015. Data were analyzed from January to December 2019. Main Outcomes and Measures: Danish health registers were used to identify mental disorder diagnoses, dates of death, and causes of death. The YLLs were estimated for the set of mental health-associated causes of death, and all-cause and cause-specific LYLs were estimated for 18 specific mental disorders and 3 broad categories of mental disorders that were recommended for use in the GBD studies. The association between the number of comorbid mental disorders (divided into categories of persons with ≥1 type of disorder, ≥2 types of disorders, ≥3 types of disorders, and ≥4 types of disorders) and LYL estimates was also examined. Results: A total of 6 989 627 individuals (3 481 219 male persons [49.8%] and 3 508 408 female persons [50.2%]; mean [SD] age at study enrollment, 32.2 [24.4] years) were followed up for a total of 85 911 461 person-years. The YLL rates per 100 000 person-years were highest for alcohol use disorder (for male individuals, 568.7 [95% CI, 564.4-572.7]; for female individuals, 155.5 [95% CI, 153.5-157.9]) and suicide (for male individuals, 590.1 [95% CI, 583.8-596.5]; for female individuals, 202.3 [95% CI, 198.5-206.4]). Although only 3 of 18 mental and substance use disorders could be associated with YLL, all mental disorders were associated with shorter life expectancies when LYL was used for measurement. Male and female individuals diagnosed with any mental disorder had life expectancies that were shorter by 11.2 years (95% CI, 11.1-11.3 years) and 7.9 years (95% CI, 7.8-8.0 years), respectively, and remaining life expectancy decreased further among those with comorbid mental disorders. Drug use disorders were associated with the highest excess LYL estimates; however, common mental disorders, such as depressive and anxiety disorders, were also associated with substantial premature mortality. Conclusions and Relevance: Mental disorders were observed to be associated with reductions in life expectancy. This finding provides a foundation for future intervention programs designed to reduce the differential mortality gap associated with mental disorders. Register-based studies allow the calculation of precise individual-level YLLs and LYLs, and both measurement methods are informative for health care planning. Compared with YLL, the novel LYL measurement approach may more precisely capture the association of mental disorders with premature mortality and facilitates the exploration of comorbidity and specific causes of death in individuals with mental disorders.

Identification of psychiatric patients with high mortality and low medical utilization: a population-based propensity score-matched analysis.

BACKGROUND: The decreased life expectancy and care costs of mental disorders could be enormous. However, research that compares mortality and utilization concurrently across the major category of mental disorders is absent. This study investigated all-cause mortality and medical utilization among patients with and without mental disorders, with an emphasis on identifying the psychiatric category of high mortality and low medical utilization. METHODS: A total of 570,250 individuals identified from the 2002-2013 Taiwan National Health Insurance Reearch Database consistuted 285,125 psychiatric patients and 285,125 non-psychiatric peers through 1:1 dual propensity score matching (PSM). The expenditure survival ratio (ESR) was proposed to indicate potential utilization shortage. The category of mental disorders and 13 covariates were analyzed using the Cox proportional hazard model and general linear model (GLM) through SAS 9.4. RESULTS: PSM analyses indicated that mortality and total medical expenditures per capita were both significantly higher in psychiatric patients than those in non-psychiatric patients (all P <.0.0001). Patients with substance use disorders were reported having the youngest ages at diagnosis and at death, with the highest 25.64 of potential years of life loss (YPLL) and relevant 2904.89 of ESR. Adjusted Cox model and GLM results indicated that, compared with anxiety disorders, affective disorders and substance use disorders were significantly associated with higher mortality (HR = 1.246 and 1.064, respectively; all P < 0.05); schizophrenia was significantly associated with higher total medical expenditures per capita (P < 0.0001). Thirteen additional factors were significantly associated with mortality or utilization (all P < 0.05). CONCLUSION: Substance use disorders are the category of highest YPLL but notably in insufficient utilization. Health care utilization in patients with substance use disorders should be augmented timely after the diagnosis, especially toward home and community care. The factors related to mortality and utilization identified by this study merit clinical attention.

Cancer Screening in Behavioral Health Care Programs.

OBJECTIVE: Adults with serious mental illnesses have a lower life expectancy attributable to many factors including metabolic disorders and cancer. Access to cancer screening has been shown to decrease morbidity and increase chances of survival. This study examined access to cancer screening services among individuals with serious mental illnesses served by a community behavioral health care agency partial hospitalization program at four locations. METHOD: A self-administered paper-and-pencil survey was provided to adults attending partial hospitalization programs. The survey consisted of open- and closed-ended questions about utilization, access to, and barriers to cervical, breast, and colorectal cancer screenings. RESULTS: Surveys were completed by 136 individuals. Participant screening rates were above national rates for cervical and breast cancer but lower for colorectal cancer. The main cited barrier to receiving the screening tests was lack of physician recommendations. CONCLUSIONS: Psychiatric nurses are ideally suited to communicate with this population and other behavioral health care professions about the importance of these screenings. Communication should also advocate for improved education and increased support for cancer screenings to address this health care disparity.

Overwork-related disorders and recent improvement of national policy in South Korea.

OBJECTIVES: Recently, overwork-related disorders have become a major public health concern in Korea. This study investigated the current trends of working hours, causes of death in the working population, and compensation rates. METHODS: We reviewed the current trends of working hours, cause of death statistics in the working population, industrial accident compensation insurance (IACI) statistics, issues of compensation and prevention of work-related cerebro-cardio vascular diseases (CCVDs), mental disorders, and suicide. RESULTS: Although weekly working hours and the proportion of long working days have decreased, workers in small companies with fewer than five employees and those in the service sector continue to work long hours. The age standardized mortality due to CCVD and suicide was highest among those with managerial roles. In total, 589 CCVD cases and 104 mental disorder or suicide cases were compensated as occupational diseases in 2017. Between 2016 and 2017, 61% of 59 compensated suicides were related to overwork, specifically: long working hours, increased responsibility, or increased workload. The Korean government has introduced various policies to reduce working hours and to increase compensation approval rate for overwork-related CCVDs. Stakeholders have called for the introduction of independent laws to prevent overwork-related disorders, change organizational culture, and address the blind spots of the IACI Act and Labor Standard Act. CONCLUSIONS: Prevention and compensation policies have improved working conditions in Korea, but there remains much to be done. This review significantly contributes to the understanding of the overall policies and research to prevent overwork-related disorders in Korea.

Cost of Acute and Follow-Up Care in Patients With Pre-Existing Psychiatric Diagnoses Undergoing Radiation Therapy.

PURPOSE: The impact of psychiatric comorbidities on the cost of cancer care in radiation oncology practices is not well studied. We assessed the acute and 24-month follow-up costs for patients with and without pre-existing psychiatric comorbidities undergoing radiation therapy. METHODS AND MATERIALS: Patients with cancer undergoing radiation therapy at our institution from 2009 to 2014 were denoted as having pre-existing psychiatric conditions (Psych group) if they had associated billing codes for any of the 422 International Classification of Diseases, 9th revision psychiatric conditions during the 12 months before their cancer diagnosis. The Elixhauser comorbidity index was calculated, excluding psychiatric categories. Medicare reimbursement was assigned to professional services, and Medicare departmental cost-to-charge ratios were applied to service line hospital charges and adjusted for inflation to create 2017 standardized costs. Acute (0-6 month) and follow-up (6-24 month) costs were subcategorized into clinic, emergency department, hospital inpatient, and outpatient costs. RESULTS: Among 1275 patients, 126 (9.9%) had at least 1 pre-existing psychiatric diagnosis. On univariate analysis, both acute and long-term costs were higher in the Psych group. The largest significant differences in costs were follow-up hospital inpatient costs ($5861 higher; 95% confidence interval [CI], $687-$11,035; P = .002), follow-up hospital outpatient costs ($2086 higher; 95% CI, -$142 to $4,314; P = .040), and follow-up emergency department costs ($396 higher; 95% CI, $149-$643; P < .001). Age, race, sex, and treatment modalities were comparable, but the Psych group patients had more median comorbidities (2 vs 1) and had more respiratory cancer diagnoses than the nonpsychiatric group (31% vs 17%). On multivariate analysis adjusted for age, sex, cancer diagnosis, and comorbidities, global follow-up costs remained 150% higher in the Psych group (P < .001). Acute costs were similar after adjustment (P = .63). CONCLUSIONS: Psychiatric comorbidities independently predict elevated healthcare costs in patients treated for cancer. Radiation oncology payment models should consider adjustments to account for psychiatric comorbidities because addressing these may mitigate cost differential.

The burden of psychiatric illnesses in adult patients with beta-thalassemia: a 5-year nationwide inpatient evaluation in the United States.

Beta-thalassemia (ß-thalassemia) is a frequently inherited monogenic disorder worldwide with severe physical and mental health comorbidities. The aim of this study is to evaluate the burden of psychiatric disorders in adult patients hospitalized with ß-thalassemia in the United States (US). We utilized the discharge data from the National Inpatient Sample (NIS) from 2010 through 2014 to identify hospitalized ß-thalassemia patients who are 18 years and older. We assessed categorical and continuous variables using chi-square test and Student's t test respectively. The burden of psychiatric disorders was assessed using descriptive statistics and represented in terms of frequency (n) and percentage (%). A p value threshold of < 0.05 was considered clinically significant. All statistical analyses were performed using SPSS version 22.0 (IBM Corp., Armonk, NY, USA). Of the 10,046 ß-thalassemia patients studied, 24.4% (n = 2448) reported psychiatric disorders. Mood disorders (15.2%; inclusive of 10.3% depression), followed by anxiety (9.4%), and substance abuse disorder (6.5%; 4.3% drug abuse, 2.2% alcohol abuse) were most prevalent. Comorbid mental illnesses increased the length of stay by 44.6% and total costs by 23.4%. All-cause mortality rate was reported at 1.9% in overall ß-thalassemia patients. This study highlights higher rates of psychiatric disorders such as depression and anxiety and correlated increases in length of stay and cost in hospitalized ß-thalassemia patients. To improve medical outcomes and curtail unnecessary health-care costs, implementation of an integrated care model can be considered.

Digital technology for health promotion: opportunities to address excess mortality in persons living with severe mental disorders.

Persons with severe mental disorders (SMDs) experience dramatically reduced life expectancy compared with the general population. We consider the role of digital technologies for addressing this serious public health concern. In this clinical review, we apply the multilevel risk model recently introduced by the WHO to conceptualise how digital technology can support efforts to reduce excess mortality risk at the individual, health system and social determinants of health levels. In particular, digital technologies show promise for targeting preventable physical health conditions in persons with SMDs. However, evidence on the use of these technologies for addressing early mortality risk factors is lacking. At the individual level, digital interventions show promise for managing mental health symptoms, promoting healthy lifestyle behaviours and targeting substance use concerns. At the health system level, digital interventions can support care coordination, clinician training, screening and monitoring health indices and shared decision-making. At the social determinants of health level, digital interventions can facilitate opportunities to engage peers for illness self-management and health promotion and for delivering and/or augmenting supported employment programmes. The time is ripe to capitalise on early evidence to support future development, testing and delivery of effective digital efforts targeting risk factors that contribute to shorter life expectancy in persons with SMDs. Key challenges and opportunities for future research include increasing user engagement, involving users during development and testing of digital interventions, carefully considering risks/harms and rigorously evaluating effectiveness and costs to support the scalability and sustainability of promising digital approaches.

Development of Indicators for Public Health Surveillance of Substance Use and Mental Health.

Substance use and mental health disorders can result in disability, death, and economic cost. In the United States, rates of death from suicide, drug overdose, and chronic liver disease (a marker for alcohol abuse) have been rising for the past 15 years. Good public health surveillance for these disorders, their consequences, and their risk factors is crucially important for their prevention and control, but surveillance has not been conducted consistently in the states. In 2015, the Council of State and Territorial Epidemiologists convened a workgroup to develop a set of uniformly defined surveillance indicators that could be used by state and local health departments to monitor these disorders and to compare their occurrence in various jurisdictions. This report briefly describes the indicators and outlines the process used to develop them.

[Psychiatric sick leave]. / Licencia médica psiquiátrica: revisión de los efectos positivos y negativos del reposo.

There is no consensus amongst physicians, social security representatives and researchers about optimum sick leaves. This is an indication that should maximize positive outcomes and minimize potential side effects, both for the patient and society. The use of sick leaves during the last decade rose steadily, particularly in the psychiatric field. The most important causes of this increase are: changes in public policies, overuse of psychiatric diagnosis to cover up unmet social needs, and modifications to labour structure. It is analysed the impact that this situation has implied for physician patient relationship as well as for health budget. Even though sick leave diminishes presentism associated to a psychiatric disorder, published evidence about the effect of prolonged sick leave shows that damage overruns potential benefits: augmented morbidity and mortality, workplace phobia, economic loss, among others.

Licencia médica psiquiátrica: revisión de los efectos positivos y negativos del reposo / Psychiatric sick leave

There is no consensus amongst physicians, social security representatives and researchers about optimum sick leaves. This is an indication that should maximize positive outcomes and minimize potential side effects, both for the patient and society. The use of sick leaves during the last decade rose steadily, particularly in the psychiatric field. The most important causes of this increase are: changes in public policies, overuse of psychiatric diagnosis to cover up unmet social needs, and modifications to labour structure. It is analysed the impact that this situation has implied for physician patient relationship as well as for health budget. Even though sick leave diminishes presentism associated to a psychiatric disorder, published evidence about the effect of prolonged sick leave shows that damage overruns potential benefits: augmented morbidity and mortality, workplace phobia, economic loss, among others.

The prevalence and burden of mental and substance use disorders in Australia: Findings from the Global Burden of Disease Study 2015.

OBJECTIVES: Timely and accurate assessments of disease burden are essential for developing effective national health policies. We used the Global Burden of Disease Study 2015 to examine burden due to mental and substance use disorders in Australia. METHODS: For each of the 20 mental and substance use disorders included in Global Burden of Disease Study 2015, systematic reviews of epidemiological data were conducted, and data modelled using a Bayesian meta-regression tool to produce prevalence estimates by age, sex, geography and year. Prevalence for each disorder was then combined with a disorder-specific disability weight to give years lived with disability, as a measure of non-fatal burden. Fatal burden was measured as years of life lost due to premature mortality which were calculated by combining the number of deaths due to a disorder with the life expectancy remaining at the time of death. Disability-adjusted life years were calculated by summing years lived with disability and years of life lost to give a measure of total burden. Uncertainty was calculated around all burden estimates. RESULTS: Mental and substance use disorders were the leading cause of non-fatal burden in Australia in 2015, explaining 24.3% of total years lived with disability, and were the second leading cause of total burden, accounting for 14.6% of total disability-adjusted life years. There was no significant change in the age-standardised disability-adjusted life year rates for mental and substance use disorders from 1990 to 2015. CONCLUSION: Global Burden of Disease Study 2015 found that mental and substance use disorders were leading contributors to disease burden in Australia. Despite several decades of national reform, the burden of mental and substance use disorders remained largely unchanged between 1990 and 2015. To reduce this burden, effective population-level preventions strategies are required in addition to effective interventions of sufficient duration and coverage.

Care coordinator views and experiences of physical health monitoring in clients with severe mental illness: A qualitative study.

BACKGROUND: Excess mortality among people with severe mental illness (SMI) is largely attributed to co-morbid physical illness. Improving the physical health of this population is critically important; however, physical health monitoring among people with SMI is often inadequate. AIMS: This study aimed to facilitate an enhanced understanding of barriers to successfully attend to clients' physical health in mental health settings, through exploring care coordinators' views and experiences regarding their ability to monitor physical health in clients with SMI (specifically, psychosis). METHODS: Semi-structured interviews were conducted with seven care coordinators from a South East London (UK) community mental health team. Data were analysed using thematic analysis principles. RESULTS: Three themes were identified in these data, capturing (1) how care coordinators viewed the professional roles of other clinical staff and themselves, (2) views on barriers to the provision of physical healthcare and (3) factors that motivated care coordinators to attend to clients' physical health. CONCLUSION: Our findings can inform efforts to implement physical healthcare interventions within mental health settings. Such insights are timely, as academic literature and guidelines regarding clinical practice increasingly promote the value of integrated provision of mental and physical healthcare.