The Role of Decision-Making Capacity in Gathering Collateral Information.

AbstractPsychiatric disorders usually do not have characteristic physical exam findings, imaging, or lab values. Psychiatrists therefore diagnose and treat patients largely based on reported or observed behavior, which makes collateral information from a patient's close contacts especially pertinent to an accurate diagnosis. The American Psychiatric Association considers communication with patients' supports a best practice when the patient provides informed consent or does not object to the communication. However, situations arise in which a patient's objection to such communication is the product of impaired decision-making and the benefits of obtaining collateral information represent best practice. In this article a framework for addressing these situations is proposed using a full decisional capacity evaluation, followed by an alternate decision-making process by concurrence from a second physician. It is recommended that a patient's refusal to allow the gathering of collateral information should be addressed exactly like refusals for other diagnostic or treatment interventions.

Delirium is a robust predictor of morbidity and mortality among critically ill patients treated in the cardiac intensive care unit.

BACKGROUND: Delirium is common in the medical and surgical intensive care unit (ICU), and its association with morbidity and mortality is well described. Despite emerging data, which have highlighted a growing critical care burden in the contemporary cardiac ICU (CICU), much less is known about delirium in this specialized setting. METHODS AND RESULTS: Records for consecutive CICU patients aged ≥18 years who were admitted to our academic, tertiary care institution from December 2012 to March 2014 for a primary cardiovascular diagnosis were reviewed. Only those with a documented Confusion Assessment Method for ICU score were included in the final analysis. Baseline characteristics, resource use, and outcomes were collected. Disease severity was assessed using the modified Acute Physiology and Chronic Health Evaluation II score and the Simplified Acute Physiology ScoreII. Multivariable logistic and linear regression models were constructed to evaluate the association between CICU delirium, length of stay, and death. Among 590 patients included, the prevalence of CICU delirium was 20.3%. Delirious patients were older, had greater disease severity, required longer ICU stays (5 vs 2 days; P < .001), and had higher mortality (27% vs 3%; P < .001). In the adjusted setting, delirium remained strongly associated with both increased mortality (P < .001) and length of stay (P = .001). CONCLUSIONS: In those with cardiac critical illness, delirium is common and associated with worse survival and greater resource consumption. Future study is needed to validate these findings and to develop effective strategies for the early identification and treatment of the delirious CICU patient.

Strategies utilized to prevent and control SARS-CoV-2 transmission in two congregate, psychiatric healthcare settings during the pandemic.

BACKGROUND: The COVID-19 pandemic has had a substantial effect on the delivery of psychiatric health care. Inpatient psychiatric health care facilities have experienced outbreaks of COVID-19, making these areas particularly vulnerable. METHODS: Our facility used a multidisciplinary approach to implement enhanced infection prevention and control (IPC) interventions in our psychiatric health care areas. RESULTS: In a 16-month period during the COVID-19 pandemic, our 2 facilities provided >29,000 patient days of care to 1,807 patients and identified only 47 COVID-19 positive psychiatric health inpatients (47/1,807, or 2.6%). We identified the majority of these cases by testing all patients at admission, preventing subsequent outbreaks. Twenty-one psychiatric health care personnel were identified as COVID+ during the same period, with 90% linked to an exposure other than a known positive case at work. DISCUSSION: The IPC interventions we implemented provided multiple layers of safety for our patients and our staff. Ultimately, this resulted in low SARS-CoV-2 infection rates within our facilities. CONCLUSIONS: Psychiatric health care facilities are uniquely vulnerable to COVID-19 outbreaks because they are congregate units that promote therapeutic interactions in shared spaces. IPC interventions used in acute medical care settings can also work effectively in psychiatric health care, but often require modifications to ensure staff and patient safety.

Implementation of a Psychiatry Consultation-Liaison Service "Conseminar".

BACKGROUND: The field of consultation-liaison psychiatry has generated a relatively small number of rigorous clinical trials that guide clinical care. Consequently, there is a need for a consensus-building process to inform best practices for common clinical dilemmas in consultation-liaison psychiatry. OBJECTIVE: We review several consensus-building approaches in academic medicine and describe a novel educational process called a "conseminar," which is intended to minimize the variability in teaching and practice on a service staffed by multiple faculty members. METHODS: The conseminar is an iterative group exercise among faculty who attend on a consultation-liaison service. Faculty members generate a list of candidate topics and then prioritize those topics for a focused and critical literature review, aided by a librarian. In the absence of definitive clinical trial data or established practice guidelines, the faculty articulates a consensus "best-practice" approach and creates a brief document that summarizes specific recommendations for learners on the service. CONCLUSIONS: The conseminar process can minimize variability among consultation-liaison faculty within a single institution with respect to the diagnostic and treatment recommendations conveyed to trainees. Furthermore, conseminar documents can be shared across institutions to promote more consistent teaching and practice within consultation-liaison psychiatry.

Burn recidivism: a 10-year retrospective study characterizing patients with repeated burn injuries at a large tertiary referral burn center in the United States.

BACKGROUND: Psychiatric and substance use disorders are common among trauma and burn patients and are known risk factors for repeat episodes of trauma, known as trauma recidivism. The epidemiology of burn recidivism, specifically, has not been described. This study aimed to characterize cases of burn recidivism at a large US tertiary care burn center and compare burn recidivists (RCs) with non-recidivists (NRCs). METHODS: A 10-year retrospective descriptive cohort study of adult burn patients admitted to the North Carolina Jaycee Burn Center was conducted using data from an electronic burn registry and the medical record. Continuous variables were reported using medians and interquartile ranges (IQR). Chi-square and Wilcoxon-Mann-Whitney tests were used to compare demographic, burn, and hospitalization characteristics between NRCs and RCs. RESULTS: A total of 7134 burn patients were admitted, among which 51 (0.7%) were RCs and accounted for 129 (1.8%) admissions. Of the 51 RCs, 37 had two burn injuries each, totaling 74 admissions as a group, while the remaining 14 RCs had between three and eight burn injuries each, totaling 55 admissions as a group. Compared to NRCs, RCs were younger (median age 36 years vs. 42 years, p = 0.02) and more likely to be white (75% vs. 60%, p = 0.03), uninsured (45% vs. 30%, p = 0.02), have chemical burns (16% vs. 5%, p <  0.0001), and have burns that were ≤ 10% total body surface area (89% vs. 76%, p = 0.001). The mortality rate for RCs vs. NRCs did not differ (0% vs. 1.2%, p = 0.41). Psychiatric and substance use disorders were approximately five times greater among RCs compared to NRCs (75% vs. 15%, p <  0.001). Median total hospital charges per patient were nearly three times higher for RCs vs. NRCs ($85,736 vs. $32,023, p <  0.0001). CONCLUSIONS: Distinct from trauma recidivism, burn recidivism is not associated with more severe injury or increased mortality. Similar to trauma recidivists, but to a greater extent, burn RCs have high rates of comorbid psychiatric and medical conditions that contribute to increased health care utilization and costs. Studies involving larger samples from multiple centers can further clarify whether these findings are generalizable to national burn and trauma populations.

Treatment outcome variation between depression symptom combinations in the STAR*D study.

BACKGROUND: In response to recent documentation of symptom and subtype heterogeneity in major depressive disorder, we report on exploratory analyses of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) clinical-trial data to further describe heterogeneity in depression and test the hypothesis that citalopram treatment-outcome patterns differ as a function of depression symptom combinations. METHODS: Combinatorial algorithms, latent profile analysis, and repeated-measures multivariate analysis of variance were employed to characterize heterogeneity and depression outcome-measure profile variability in the most prevalent symptom combinations with full data (26% of baseline and 13% of endpoint total sample). RESULTS: Descriptive results suggest that substantial heterogeneity and moderate coherence characterize major depressive disorder; as in previous analyses, pairs of individuals sharing no symptoms in common were observed. Exploratory latent profile analysis indicated that different patterns of treatment outcome data exist among STAR*D participants. A small but significant interaction effect of symptom combination×outcome measure profile was observed for clinician-rated but not self-reported symptom combinations. LIMITATIONS: Factors moderating the generalizability of these findings include binary symptom measures, a short treatment period, and a smaller number of individuals per combination. CONCLUSIONS: These results provide evidence that citalopram treatment outcomes vary as a function of diagnostic combinations, thereby providing preliminary evidence that the substantial heterogeneity documented in depression symptom presentations may carry implications for prognosis and treatment outcome. At the level of descriptive phenomenology, these results appear to corroborate the claim that depression is not a homogenous syndrome.

Serotonin syndrome caused by fentanyl and methadone in a burn injury.

Serotonin syndrome is a syndrome identified by a triad of altered mental status, neuromuscular overactivity, and autonomic instability caused by the overstimulation of serotonin in the central nervous system and periphery. Serotonin syndrome may be provoked with the addition or increase in serotonergic agents such as selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, tricyclic antidepressants, and monoamine oxidase inhibitors as well as other agents with serotonergic properties. Some narcotics, including fentanyl and methadone, have these properties and may be associated with the development of serotonin syndrome when used in conjunction with other agents. Currently, there are no identified case reports of narcotics as the sole agent causing serotonin syndrome. This report provides a brief overview of serotonin syndrome, particularly with cases involving administration of narcotics such as fentanyl and methadone. The case described is the first report associated with fentanyl and methadone without the coadministration of other serotonergic agents, and a possible drug interaction with voriconazole is discussed. This raises awareness of using multiple serotonergic narcotics and the potential precipitation of serotonin syndrome.

Quantifying heterogeneity attributable to polythetic diagnostic criteria: theoretical framework and empirical application.

Heterogeneity within psychiatric disorders is both theoretically and practically problematic: For many disorders, it is possible for 2 individuals to share very few or even no symptoms in common yet share the same diagnosis. Polythetic diagnostic criteria have long been recognized to contribute to this heterogeneity, yet no unified theoretical understanding of the coherence of symptom criteria sets currently exists. A general framework for analyzing the logical and mathematical structure, coherence, and diversity of Diagnostic and Statistical Manual diagnostic categories (DSM-5 and DSM-IV-TR) is proposed, drawing from combinatorial mathematics, set theory, and information theory. Theoretical application of this framework to 18 diagnostic categories indicates that in most categories, 2 individuals with the same diagnosis may share no symptoms in common, and that any 2 theoretically possible symptom combinations will share on average less than half their symptoms. Application of this framework to 2 large empirical datasets indicates that patients who meet symptom criteria for major depressive disorder and posttraumatic stress disorder tend to share approximately three-fifths of symptoms in common. For both disorders in each of the datasets, pairs of individuals who shared no common symptoms were observed. Any 2 individuals with either diagnosis were unlikely to exhibit identical symptomatology. The theoretical and empirical results stemming from this approach have substantive implications for etiological research into, and measurement of, psychiatric disorders.

Use of lamotrigine in a patient with a clozapine-related seizure.

Seizures can be a serious adverse effect of clozapine, often a last-resort antipsychotic with unique efficacy for some patients. Several anticonvulsants have been reported to be useful in preventing further clozapine-induced seizures and permitting continued treatment with this medication. The authors describe the first reported successful use of lamotrigine for this purpose.