Psychiatric comorbidities in adults with sickle cell disease: A narrative review.

Although descriptions of quality of life and patient reports of mood in sickle cell disease (SCD) have become more common in the literature, less is known about psychiatric illness prevalence, presentation, and treatment, particularly for adults. We provide a narrative review of what is known about common and debilitating psychiatric conditions such as depression, anxiety, and cognitive impairment, specifically for adults with SCD. We discuss the limitations of the current evidence, make provisional recommendations, and identify opportunities for research and improved care.

Fertility Concerns and Access to Care for Stem Cell Transplantation Candidates with Sickle Cell Disease.

Sickle cell disease (SCD) affects 100,000 Americans and causes significant psychiatric illness and poor quality of life in many domains, including infertility. Hematopoietic cell transplantation (HCT) is the only available cure for SCD, but it can entail chronic toxicities, including psychiatric conditions, such as depression and anxiety, and sterility in both men and women. There is scant literature on fertility or psychiatric outcomes for patients with SCD receiving HCT, and none considering the additive ramifications of the stresses of SCD, transplantation, and infertility. Financial toxicity is a significant concern for all patients undergoing HCT. Treatment for infertility is also very expensive, and access to fertility services is variable in the United States, adding to the medical and quality of life burden for this patient population. Here we review the relevant areas of SCD and infertility, SCD and psychiatric wellness, access to care, and infertility and quality of life. Collectively, these data suggest that the group of patients with SCD who undergo HCT and experience infertility are at particularly high risk for poor quality of life, worsening psychiatric health, and poor access to adequate fertility treatment.

The Incapacitated Surrogate: What is the Consultation-Liaison Psychiatrist's Role?

BACKGROUND: When a patient is found to be lacking capacity to make a medical decision, the medical team is advised to turn to the patient's most appropriate surrogate decision maker (hereafter, surrogate) to make a choice on behalf of the patient. The assumption made by the medical team is that the surrogate will have the capacity to make appropriate medical decisions on behalf of the patient. At times though, the capacity of the surrogate himself may be called into question, leading to uncertainty in terms of how best to proceed in the care of the patient. Consultation-liaison psychiatrists are commonly consulted to assess a patient's capacity to make a particular medical decision, but their role assisting in cases of incapacitated surrogates is less clear. OBJECTIVE: In this article, we summarize the existing literature and current state laws regarding incapacitated surrogates and propose guidelines for the role the consultation-liaison psychiatrist can take when the surrogate may be incapacitated.

Standardized Semi-structured Psychosocial Evaluation before Hematopoietic Stem Cell Transplantation Predicts Patient Adherence to Post-Transplant Regimen.

In patients undergoing stem cell transplantation (SCT), nonadherence has potential for significant medical impact and potentially life-threatening complications. No study thus far has demonstrated an effective way to predict adherence in SCT recipients. A structured rating scale, the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT), has been shown to predict psychosocial outcomes and medical morbidity in solid organ transplant recipients. We assessed the SIPAT in SCT recipients. We hypothesized that the SIPAT rating would be associated with nonadherence to the post-SCT regimen. We retrospectively studied SCT recipients who had psychiatric evaluations with the SIPAT before SCT. The primary outcome was nonadherence, defined a priori as at least 1 life-threatening nonadherence event in the first 6 months post-transplant. Association of the SIPAT with outcomes was evaluated by logistic regression, and an optimal cutoff score was determined using a receiver operating characteristic curve. Of 85 patients (mean age 47 years; range, 18 to 74 years), 56 (66%) were male, and 43 (50.5%) received autologous SCT. Eighteen (21%) patients were nonadherent. The SIPAT rating, treated as a continuous variable and controlling for autologous versus allogeneic SCT, was significantly associated with nonadherence (per 1 point; odds ratio [OR], 1.162; P< .0001). Allogeneic SCT also conferred a significantly increased risk of nonadherence (OR, 14.184; P= .005). Multivariate analysis stratifying for allogeneic versus autologous transplantation and controlling for age, sex, and disease confirmed an independent association between the SIPAT score and nonadherence. A cutoff score of 18 provided optimal specificity (89.6%) and sensitivity (55.6%) for nonadherence. Nonadherence rates were 58.8% and 11.8% for subjects with SIPAT ratings of 18 and above or 17 and below, respectively (relative risk = 4.98, P < .0001). Psychosocial risk as quantified by the SIPAT correlated with SCT recipients' adherence to the post-transplant regimen, suggesting that this instrument can contribute to medical risk stratification models. Further study should evaluate long-term mortality data and the effects of intervention on psychosocial risks.

"What We Have Here is a Failure to Communicate": Association of Preferred Language With the Rate of Psychiatric Consultation.

BACKGROUND: In the United States, people with limited English proficiency (LEP) receive poorer medical care than those proficient in English. Few studies demonstrate how linguistic barriers complicate psychiatric care; in consultation-liaison (C-L) psychiatry, there are no published data about care disparities for patients with LEP or for whom English is not the preferred language (PL). OBJECTIVE: We sought to determine if PL affects the psychiatric consultation rate. METHODS: Among adult patients admitted during 1 year to a large urban academic medical center, we compared psychiatric consultation rates in English PL patients with non-English PL patients. PL was ascertained from demographics during the medical record. The occurrence of psychiatric consultation was ascertained from C-L service logs. RESULTS: There were 54,534 admissions: the no-consultation group (N = 53,196) and the consultation group (N = 1,398). English as PL was more common in the consult group (72.0% of consult group, 62.0% of no-consult group, χ2 = 92.98, p < 0.0001). Spanish speakers were underrepresented in the consult group (14.2% of consult, 25.8% of no-consult, χ2 = 98.78, p < 0.0001). CONCLUSION: Primary teams requested more consultations for patients whose PL was English than for patients with other PLs, suggesting that psychiatric needs of patients with non-English PL may be unaddressed. This is the first study to demonstrate a disproportionately low rate of general hospital psychiatric consultations in this population. Further study is necessary to confirm and understand this disparity. We recommend routine use of professional interpreters and low threshold for consultation in patients with non-English PL.

Ensuring privacy in telemedicine: Ethical and clinical challenges.

Data privacy in telemedicine has been extensively considered and reviewed in the literature, such as explorations of consent, who can access information, and the security of electronic systems. However, privacy breaches are also a potential concern in the physical setting and surroundings of the patient. Here we review clinical situations in which there is unanticipated loss of privacy, as well as potential physical and psychological safety concerns for the patient and others when privacy is limited. We identify ethical concerns and explore the challenges of supporting full true autonomous decision-making in this situation. We close with preliminary recommendations at the patient, clinician, and systems levels to help ensure privacy is maintained.

Consultation-Liaison Telepsychiatry: A Coded Thematic Analysis of Clinicians' Reported Experiences.

BACKGROUND: Telepsychiatry is now common practice. Within consultation-liaison psychiatry (CLP), previous work has shown that telepsychiatry is feasible and satisfactory. To date, there has not been qualitative work done within CLP to describe the clinician's experience with telepsychiatry. OBJECTIVE: This study aimed to perform a thematic analysis of clinicians' perceived benefits and limitations of providing telepsychiatry in CLP. METHODS: An anonymous clinician survey querying demographics, education, training, technological experience, and practice characteristics was distributed via social media and professional listservs, the quantitative results of which are presented elsewhere. Two questions (What was the best/worst aspect of adapting to telepsychiatry?) required free-text responses; comments were allowed elsewhere. We performed a thematic analysis of the text responses because of its flexibility and ability to develop new insights. We synthesized and generated a codebook iteratively. Initial coding was completed by 3 co-authors independently, followed by discussion to build consensus. We used qualitative content analysis to better understand common trends and frequencies in the data. Saturation of themes was reached. RESULTS: A total of 333 behavioral health clinicians completed the survey, including 197 CLP participants. Most respondents (98.5%) responded to at least 1 open-answer question, with 314 reporting the worst aspects of telepsychiatry and 315 reporting the best aspects. Respondents made insightful comments about boundaries, public health implications, and the need for training. We categorized the results into implications for practice, therapeutic relationship, and uniquely affected populations. CONCLUSIONS: These results show that telepsychiatry has both unique benefits and limitations within CLP. Our work examines and describes these nuances. We believe that future use of telepsychiatry will be synergistic with in-person care and that the 2 modalities will be used together to maximize benefits. A public health focus on improving Internet access and simplifying interstate licensure would improve equitable access and utilization of outpatient telepsychiatry. Telepsychiatry can be successful for inpatient Consultation-Liaison work but requires thoughtful triage and teamwork.

The Stresses of Surrogate Decision-Making: Contributing Factors and Clinicians' Role in Mitigation.

BACKGROUND: Surrogate Decision-Makers (surrogates) are frequently employed in decision-making for critically ill adults. There are insufficient data considering the surrogate experience, stress, and potential for mitigation. METHODS: An anonymous online survey queried (1) medical situation (2) total stress (3) demographics (4) potential factors, including sources of information about patient wishes, external sources of support or competing stressors, and their interactions with the medical team through the experience. RESULTS: 108 respondents were included; 91 completed all items. Most respondents ranked their experience as a surrogate as one of the most stressful experiences of their lives; this was associated with whether it was an end-of-life decision (P = .003), Respondent Religion (P = .015), or religious or spiritual beliefs (P = .024), and having their own health problems (P = .008). On individual Likert responses, surrogates reported significant stress mitigation when they felt they had been helpful (P < .001), knew the patient's wishes (P = .0011), specifically discussed patient wishes (P < .001), or patient's wishes were documented (P < .001). Items about surrogate-team interaction also met significance, including the physician being communicative and available (P < .001), respectful (P = .007), honest (P < .001), and validating (P = .001). CONCLUSIONS: Surrogate stress is an evolving area for research. Significant factors included relationship with the medical team, making this an important area for HPM to play a key role in mitigating surrogate stress.

Expecting more: the case for incorporating fertility services into comprehensive sickle cell disease care.

Assisted reproductive technologies (ART) are not yet systematically available to people with sickle cell disease or their parents. Fertility care for these groups requires addressing sickle cell disease-associated infertility risks, fertility preservation options, pregnancy possibilities and outcomes, and, when needed, infertility treatment. People with a chance of having a child with sickle cell disease can use in-vitro fertilisation with preimplantation genetic testing to conceive a child unaffected by sickle cell disease. Also, parents of children with sickle cell disease can use this technology to identify embryos to become potential future matched sibling donors for stem cell transplant. In the USA, disparities in fertility care for the sickle cell disease community are especially stark. Universal screening of newborn babies' identifies sickle cell disease and sickle cell trait, guidelines direct preconception genetic carrier screening, and standard-of-care fertility preserving options exist. However, potentially transformative treatments and cures for patients with sickle cell disease are not used due to iatrogenic infertility concerns. In diversely resourced care settings, obstacles to providing fertility care to people affected by sickle cell disease persist. In this Viewpoint, we contend that fertility care should be incorporated into the comprehensive care model for sickle cell disease, supporting alignment of treatment goals with reproductive life plans and delivering on the promise of individualised high-quality care for people with sickle cell disease and their families. We consider the obligation to provide fertility care in light of medical evidence, with acknowledgment of formidable obstacles to optimising care, and powerful historical and ethical considerations.

Incorporating gonadal health counseling into pediatric care of sickle cell patients.

Discussions regarding gonadal function and possible disease or treatment-related ovarian or testicular dysfunction, sexual dysfunction, and possible future infertility can be challenging in the sickle cell disease (SCD) pediatric care setting. A construct that stratifies topics into those that are time sensitive and those that require reproductive care expertise vs address gonadal health as a part of normal SCD care may be helpful. Pediatric health care discussions of gonadal function/dysfunction for patients with SCD can include (1) time-sensitive fertility consults preceding the start of gonadotoxic therapy and (2) targeted discussions at key time points during normally scheduled hematology clinic visits. The former conversations are best led by individuals with expertise in the risk for treatment-related infertility and fertility preservation. The latter discussions can be incorporated into targeted regularly scheduled visits with hematologists. These topics can be addressed as a part of planned education in pediatric care for adolescents and incorporated into transition plans as young adults transfer care to adult providers. Although the topics of puberty and gonadal health can be uncomfortable and many complex interdisciplinary and ethical issues arise in this process, these discussions can be aided by the collaterals and teaching handouts presented in this article.

Survey of Clinician Experiences of Telepsychiatry and Tele-Consultation-Liaison Psychiatry.

BACKGROUND: The COVID-19 pandemic created pressure to implement telepsychiatry across practice models. OBJECTIVE: We sought to evaluate the overall success of this change and to identify what types of practice settings, provider groups, and patient groups were best served by telepsychiatry and telepsychotherapy utilization. We were particularly interested in how providers of consultation-liaison psychiatry adapted to remote care. METHODS: An anonymous provider survey querying demographics, education, training, technological experience, practice setting, treatment modalities, patient groups, transition process, and outcomes was made openly available via social media and professional listservs. We used multivariable regression modeling to evaluate for predictors of the positive outcomes of overall satisfaction, subjective ability to diagnose and treat patients adequately using exclusively telepsychiatric platforms, and patient satisfaction by proxy. RESULTS: Three hundred thirty-three respondents, mostly young (59.4% younger than 50 years), female (69.7%), and physicians (67.9%), completed the survey. One hundred ninety-seven (59.1%) worked in consultation-liaison psychiatry. Of the total, 85.9% gave affirmative answers to overall satisfaction. Multivariable linear regression models found that satisfaction was predicted by general comfort with technology (P < 0.001), but negatively correlated with having technical issues (P < 0.001), a priori skepticism (P < 0.001), clinician being male (P = 0.004), and treating LGBTQ+ patients (P = 0.022). Completeness was associated with having training in telehealth (P = 0.039) and general comfort with technology (P < 0.001) but negatively associated with treating LGBTQ+ patients (P = 0.024) or inpatients (P = 0.002). Patient satisfaction by proxy was positively associated with general comfort with technology (P < 0.001) and the respondent being a nonphysician (P = 0.004) and negatively associated with encountering a technical issue (P = 0.013) or treating inpatients (P = 0.045). Consultation-liaison psychiatrists had similar results overall and were more likely to have other staff assist in making televisits effective (mean [standard deviation]: -1.25 [3.57] versus -2.76 [3.27], P < 0.001) especially if consultative (mean [standard deviation]: -0.87 [3.67] versus -2.39 [3.01], P = 0.010). CONCLUSIONS: This study suggests high rates of overall satisfaction in telepsychiatry adoption, even in consultation-liaison psychiatry. There is distinct benefit in bolstering training, providing technical support, and addressing skepticism. Future research should include patient surveys and control groups and should focus on vulnerable populations such as sexual and gender minorities.

Pilot Assessment of Patient and Provider Characteristics Associated With Satisfactory Consultation-Liaison Telepsychiatry Encounters.

BACKGROUND: The COVID-19 pandemic created pressure to attempt remote consultation, but there are limited data on the use of telepsychiatry in general, and almost none about the experience of telepsychiatry in a consultation-liaison context. OBJECTIVE: We looked for attributes that correlated with satisfactory tele-encounters. METHODS: Eleven consultation-liaison attending surveys and 8 attendings' tele-encounter logs from March to June 2020 were completed and reviewed to assess for patient and provider characteristics associated with barriers to using telepsychiatry. RESULTS: A vast majority of 223 tele-psychiatric encounters were acceptable to providers in terms of technology (82%) and their ability to form a connection with the patient (78%). In multivariable logistic regression models, an unresolvable difficulty in using the platform was less common for female patients (odds ratio = 0.239, P = 0.002) and more common for patients who prefer a non-English language (odds ratio = 9.059, P < 0.001); achieving a personal connection that felt right was also less likely for patients who prefer a non-English language (odds ratio = 0.189, P = 0.001). CONCLUSIONS: Telepsychiatry has previously been limited to outpatient use and, generally, for providers and patients who specifically preferred it. However, abrupt transition to the use of telepsychiatry to limit contagion risk was mostly satisfactory in our center; identifying for which patient encounters it is most and least appropriate will help guide future use.

Standardized Semistructured Psychosocial Evaluation Before Stem Cell Transplantation Predicts Delirium After Transplant.

BACKGROUND: Delirium affects many patients undergoing stem cell transplantation (SCT). Delirium is treatable, but prevention is a better goal, making it desirable to identify patients at heightened risk for delirium. A standardized pretransplant psychosocial assessment rating scale, the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT), has been demonstrated to predict outcomes in solid organ transplant recipients and nonadherence in patients with SCT. OBJECTIVES: In this study, we aimed to evaluate the association of SIPAT score and post-SCT incident delirium. METHODS: We retrospectively reviewed records of SCT recipients who had SIPAT evaluations before SCT, for indications of delirium in the 6 months after transplant. We tested the association between SIPAT score and delirium by logistic regression, controlling for relevant covariates such as transplant type (allogeneic vs autologous). RESULTS: Of 85 patients (median age of 49 years, range 18-74), 56 (66%) were men, and 43 (50.5%) were autologous SCT recipients. The median pretransplant SIPAT score was 8, range 0-40. There were 15 cases (17.6%) of delirium in the 6 months following transplant.  In univariate analyses, transplant type was significantly associated with incident delirium. In multivariate analyses, SIPAT score was significantly associated with incident delirium (odds ratio, 1.090; P = 0.021). CONCLUSIONS: Psychosocial risk as quantified by the SIPAT is associated with development of delirium in SCT recipients. This scale can therefore be integrated into medical risk models to anticipate which patients are at higher risk for delirium in their hospital course, enabling preventative measures tailored to the needs of the individual patient.