Using Academic Consultation-Liaison Telepsychiatry to Meet the Mental Health Needs of Complex, Medically Ill Patients in Underserved Areas: A Case Report.

Background: The nationwide shortage of mental health resources often disproportionately affects rural areas. As innovative strategies are required to address mental health resource shortages in rural areas, telepsychiatry consultation (TPC) may represent a population health-oriented approach to bridge this gap. In this case report, we examine the use of TPC from an academic consultation-liaison psychiatry service to a rural community hospital. Case Report: We describe the case of a woman with Wernicke encephalopathy seeking to leave the hospital against medical advice and the role that the TPC service played in the patient's evaluation and management, including assessing decision-making capacity. Discussion: We then examine benefits and limitations of the service, including a narrative review of the relevant, but limited, available literature as well as suggestions for how the service may be improved and incorporated into psychiatry residency and fellowship training in the future.

Advancing the Mission of Consultation-Liaison Psychiatry Through Innovation in Teaching.

BACKGROUND: Consultation-liaison (C-L) psychiatry, similar to other medical specialties, relies on the education of students, residents, fellows, and life-long learners for growth of the field. C-L psychiatry is unique as it exists at the intersection of psychiatry with other medical subspecialties. Traditional teaching methods have been used in C-L psychiatry programs for more than 50 years, while technology has recently advanced as available resources and the learning styles of today's learners have evolved. A growing number of younger trainees are taking advantage of new ways to learn. OBJECTIVES: We sought to examine both traditional and novel teaching methodologies and how each of these educational methodologies fits within adult learning theory and in the context of how digital natives learn about C-L psychiatry. METHODS: In this narrative review, we drew upon the experiences of the authors as both life-long learners and educators. We then reviewed the literature pertaining to teaching methods that have been used in C-L psychiatry as well as emerging methods that could potentially be used in C-L psychiatry. RESULTS: C-L psychiatry has used traditional teaching methods such as readings, didactic lectures, case-based rounds, and problem-based learning. Novel teaching methodologies such as teaching rotations, simulations, social media, podcasts, movie clubs, and the use of mobile tablet computers have been used in general psychiatry and other medical specialties, while literature specific to C-L psychiatry was sparse. CONCLUSIONS: Opportunities abound to make use of new teaching methodologies and technologies to appeal to future generations of C-L psychiatrists.

Depressive Symptoms Before, During, and After Delirium: A Literature Review.

BACKGROUND: Delirium and depression are often thought of as mutually exclusive conditions. However, several studies cite depression as a risk factor for delirium whereas others note that patients with delirium often manifest depressive symptoms. Whether these depressive symptoms persist after delirium resolves remains unclear. OBJECTIVES: This article reviews published studies that have investigated the relationship between depression and delirium. METHODS: Literature searches on PubMed, CINAHL, Cochrane Library, and PsycInfo were conducted using search criteria "delirium" AND "depress⁎" as keywords or MeSH terms. RESULTS: Of 722 search results, 10 prospective cohort studies were identified for inclusion. These studies were categorized regarding the time of assessment for depressive symptoms. Included studies varied greatly (regarding their index population, their methods of assessment, and their timing of assessments). Of the studies, 3 involved patients undergoing hip fracture repair. They demonstrated more severe depressive symptoms both during delirium and after delirium ended. Conversely, the other studies did not find any statistically significant correlations between the 2 conditions. CONCLUSIONS: The literature suggests a correlation between depression and delirium in patients with hip fracture. Whether other specific populations have higher comorbidity is unclear. Unfortunately, studies varied widely in their methods, precluding a meta-analysis. Nonetheless, our review provides a foundation for future research.

Risk factors for alcohol relapse following orthotopic liver transplantation: a systematic review.

BACKGROUND: Each year, 5000-6000 individuals undergo orthotopic liver transplantation (OLT) in the United States, and of these, nearly 18% have alcoholic liver disease. Relapse to alcohol occurs in more than 40% of patients with OLT for alcoholic liver disease. OBJECTIVES: We sought to identify factors that predict relapse to alcohol or medication nonadherence following OLT in patients with alcoholic liver disease and to review what randomized clinical interventions have addressed these factors following OLT. Our hypothesis was that there would be factors before and after OLT that predict relapse to alcohol following OLT, and that these, if targeted, might improve sobriety and associated outcomes of adherence with medications and appointments. METHODS: We performed a review (focusing on articles published since 2004) with PubMed and MEDLINE searches using the following search terms: liver transplantation, recidivism, alcohol relapse, and predictors of alcohol relapse. We supplemented the online searches with manual reviews of article reference lists and selected relevant articles for further review by author consensus. RESULTS: In largely white populations, prospective studies document that shorter length of pretransplantation sobriety is a significant predictor of time to first drink and time to binge use. Presence of psychiatric comorbidity, high score on standardized High-risk Alcoholism Relapse Scale, and diagnosis of Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) alcohol dependence are predictive of posttransplantation alcohol relapse. Pretransplantation alcohol use history variables (e.g., family history of alcoholism) reliably discriminate between complete abstainers and those who drink, while medical and psychosocial characteristics at early post-liver transplantation period (e.g., more bodily pain) maximally discriminate patterns of alcohol use. Alcoholic individuals with early-onset, rapidly accelerating moderate use and early-onset, continuously increasing heavy use have more than double the prevalence of steatohepatitis or rejection on biopsy and graft failure and more frequent mortality resulting from recurrent alcoholic liver disease than late-onset (i.e., peak of heaviest drinking at 6y posttransplantation) alcohol users do. Fortunately, pretransplantation screening combined with a structured pretransplantation management program and a 12-step program attendance reduced recidivism. No randomized clinical trials have been performed that target pretransplantation risk factors in individuals with alcoholic liver disease before or after OLT to improve post-OLT outcomes. CONCLUSIONS: Recent research findings suggest that screening can reveal individuals who are vulnerable to alcohol relapse and targeted intervention can prevent their relapse to alcohol. Based on existing addiction treatments (e.g., relapse prevention plan construction), randomized clinical trials tailored to post-OLT patients should be conducted to improve their survival and quality of life.

Neuropsychiatric Complications of Hypervitaminosis D: Diagnosis, Evaluation, and Treatment.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.Prim Care Companion CNS Disord 2024;26(3):23f03680. Author affiliations are listed at the end of this article.

Decision-making in diabetes mellitus type 1.

Decreased treatment adherence in patients with diabetes mellitus type 1 (type 1 DM) may reflect impairments in decision-making and underlying associated deficits in working memory and executive functioning. Other factors, including comorbid major depression, may also interfere with decision-making. The authors sought to review the clinically relevant characteristics of decision-making in type 1 DM by surveying the literature on decision-making by patients with type 1 DM. Deficiencies in decision-making in patients with type 1 DM or their caregivers contribute to treatment nonadherence and poorer metabolic control. Animal models of type 1 DM reveal deficits in hippocampal-dependent memory tasks, which are reversible with insulin. Neurocognitive studies of patients with type 1 DM reveal lowered performance on ability to apply knowledge to solve problems in a new situation and acquired scholarly knowledge, psychomotor efficiency, cognitive flexibility, visual perception, speed of information-processing, and sustained attention. Other factors that might contribute to poor decision-making in patients with type 1 DM, include "hypoglycemia unawareness" and comorbid major depression (given its increased prevalence in type 1 DM). Future studies utilizing novel treatment strategies to help patients with type 1 DM make better decisions about their disease may improve their glycemic control and quality of life, while minimizing the impact of end-organ disease.

Financial Abuse of Older Adults: Screening, Prevention, and Interventions by Primary Care Providers.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.Prim Care Companion. 2023;25(3):22f03434. Author affiliations are listed at the end of this article.

Dynamic Evolution of Catatonia in the Context of Cerebral Venous Sinus Thrombosis.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.Prim Care Companion CNS Disord 2023;25(4):22f03471. Author affiliations are listed at the end of this article.

Neuropsychiatric Sequelae of Thyroid Dysfunction: Evaluation and Management.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.Prim Care Companion CNS Disord 2023;25(6):23f03570. Author affiliations are listed at the end of this article.

Cancer and post-traumatic stress disorder: diagnosis, pathogenesis and treatment considerations.

OBJECTIVE: The purpose of this article was to review the literature regarding diagnosis, pathogenesis, and treatment of post-traumatic stress disorder (PTSD) associated with cancer. METHOD: We surveyed studies examining the validity of diagnostic scales commonly used to measure PTSD in patients with cancer. Neurobiological underpinnings of PTSD and cancer, including inflammation as the physiological mechanism linking these comorbidities, were examined. Psychopharmacologic and psychotherapeutic treatment of PTSD symptoms in patients with cancer was reviewed. In addition, potential drug-drug interactions between psychotropic medications commonly used to treat PTSD and anti-cancer agents were reviewed. RESULTS: Multiple studies demonstrated the validity of the PTSD Checklist Civilian Version (PCL-C) in diagnosing PTSD in patients with cancer. Research has shown that PTSD as defined in DSM-IV appears to be a better model for conceptualizing distress in patients with cancer than a generalized "distress" model. Epidemiologic studies have shown an increased incidence of PTSD associated with cancer; however, literature regarding characteristics of PTSD in patients with cancer is cross-sectional in nature. SIGNIFICANCE OF RESULTS: Future research focusing on longitudinal, prospective studies to identify patients at risk, determine causal or aggravating factors, and develop preventive interventions is needed. Further study of PTSD in patients with cancer may help increase recognition of this disorder, optimize treatment, and enhance the quality of life of these individuals.

Developing, Losing, and Regaining Trust in the Doctor-Patient Relationship.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

A Patient-Centered Approach to Opioid Use Disorder.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

Non-Alcohol-Related Wernicke's Encephalopathy: Diagnosis and Treatment.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

Advancing Medical Education Through Innovations in Teaching During the COVID-19 Pandemic.

BACKGROUND: Medicine relies on education of trainees for growth of the field. Medical education has benefitted from a rapid pace of innovation, but due to the coronavirus disease 2019 (COVID-19) pandemic, many paradigms underpinning the medical education of trainees shifted-rendering numerous teaching modalities unusable. The COVID-19 pandemic, however, accelerated the development of novel teaching methodologies, which our trainees are now adapting to. We sought to examine emerging teaching methodologies to understand the opportunities available for medical education to innovate our teaching practices for learners in the midst of the COVID-19 pandemic. METHODS: In this narrative review, we drew upon the experiences of the authors as both life-long learners and educators. We then reviewed literature pertaining to novel teaching methodologies developed in medical education since the start of the COVID-19 pandemic. RESULTS: Several medical specialties have employed novel teaching methodologies including use of telemedicine, remote teaching, online curricula, virtual rotations, virtual conferences, simulations, and learning consortia to continue engaging trainees during the COVID-19 pandemic. There is a paucity of literature that addresses efficacy of novel teaching methodologies compared to more traditional teaching methodologies. CONCLUSIONS: The COVID-19 pandemic presents an opportunity for medical education to combine new and innovative teaching methodologies to create novel, accessible, and engaging learning opportunities for our trainees.

Delirious Mania: An Approach to Diagnosis and Treatment.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.