Novel Approach to Integrating Mental Health Care into a Primary Care Setting: Development, Implementation, and Outcomes.

It is now widely accepted that there is a growing discrepancy between demand and access to adequate treatment for behavioral or mental health conditions in the United States. This results in immense personal, societal, and economic costs. One rapidly growing method of addressing this discrepancy is to integrate mental health services into the primary care setting, which has become the de facto service provider for these conditions. In this paper, we describe the development and implementation of a novel integrated care program in a large mid-western university-based healthcare system, drawn from the collaborative care model, and describe the benefits in terms of both health care utilization and depression outcomes. Limitations and proposed future directions are discussed.

Psychiatric Care of the Radiation Oncology Patient.

BACKGROUND: In recent decades, psychiatrists have become increasingly involved in the care of patients with cancer. Psychiatrists are often less familiar with the field of radiation oncology than with other medical specialties. OBJECTIVE: Therefore, it is beneficial for consulting psychiatrists to be familiar with the basic principles of radiation therapy (RT) and its potential neuropsychiatric sequelae. METHODS: We performed a PubMed search to identify articles describing neuropsychiatric symptoms resulting from RT, including anxiety, claustrophobia, posttraumatic stress disorder, and neurocognitive impairment. We also searched for other sequelae of RT that may produce psychiatric symptoms, such as radiation necrosis and endocrinopathies. We provide a basic introduction to the delivery of RT. RESULTS: Psychiatrists may be involved in the treatment of patients before, during, or after RT, and each phase of treatment produces unique considerations. Anxiety about the treatment, especially the need for immobilization with a mask, can be treatment-limiting. Adverse effects from treatment, including cognitive impairment and endocrinopathies, can result in psychiatric symptoms. CONCLUSIONS: Consulting psychiatrists should be familiar with the basic principles of RT and the neuropsychiatric sequelae that may result from the treatment. Further research is needed to identify strategies to help patients tolerate RT and to identify additional preventive and therapeutic options for RT-induced cognitive impairment.

A Retrospective Analysis of Neurocognitive Impairment in Older Patients With Burn Injuries.

BACKGROUND: Older adults comprise a growing proportion of the United States population that is at risk for burns. However, few studies have examined cognitive function in this patient population. OBJECTIVE: The purpose of this study was to measure the prevalence and incidence of dementia and delirium in older adults admitted for burn injuries. METHODS: This was an Institutional Review Board-approved, retrospective study of all patients 65 years and older admitted to the University of North Carolina Jaycee Burn Center from 2005-2015. Data extracted from the medical records included patient demographics, characteristics of the burn injury, incidence of delirium, incidence of psychiatric consultation, diagnosis of dementia, disposition, and mortality. The primary outcomes of interest were the prevalence and incidence of dementia and delirium. Secondary outcomes included length of stay and cost of hospitalization. RESULTS: A total of 392 patients were included. These patients had a median age of 74 years and a median total body surface area burn of 7%. On admission, 44 patients (11%) had a diagnosis of dementia. An additional 28 patients were diagnosed with dementia during hospitalization for a total of 72 patients (18%); 154 patients (39%) were diagnosed with delirium. After controlling for burn severity, dementia and delirium were significantly associated with length of stay, incidence of psychiatry consultation, and discharge to a skilled nursing facility. CONCLUSIONS: Physicians should have high suspicion for dementia and delirium in older patients admitted for burn injuries. Dementia and delirium are associated with morbidity in older patients with burn injuries.

Taking Care of Our Own: A Multispecialty Study of Resident and Program Director Perspectives on Contributors to Burnout and Potential Interventions.

OBJECTIVE: Rates of resident physician burnout range from 60 to 76 % and are rising. Consequently, there is an urgent need for academic medical centers to develop system-wide initiatives to combat burnout in physicians. Academic psychiatrists who advocate for or treat residents should be familiar with the scope of the problem and the contributors to burnout and potential interventions to mitigate it. We aimed to measure burnout in residents across a range of specialties and to describe resident- and program director-identified contributors and interventions. METHODS: Residents across all specialties at a tertiary academic hospital completed surveys to assess symptoms of burnout and depression using the Maslach Burnout Inventory and the Patient Health Questionnaire-9, respectively. Residents and program directors identified contributors to burnout and interventions that might mitigate its risk. Residents were asked to identify barriers to treatment. RESULTS: There were 307 residents (response rate of 61 %) who completed at least one question on the survey; however, all residents did not respond to all questions, resulting in varying denominators across survey questions. In total, 190 of 276 residents (69 %) met criteria for burnout and 45 of 263 (17 %) screened positive for depression. Program directors underestimated rates of burnout, with only one program director estimating a rate of 50 % or higher. Overall residents and program directors agreed that lack of work-life balance and feeling unappreciated were major contributors. Forty-two percent of residents reported that inability to take time off from work was a significant barrier to seeking help, and 25 % incorrectly believed that burnout is a reportable condition to the medical board. CONCLUSIONS: Resident distress is common and most likely due to work-life imbalance and feeling unappreciated. However, residents are reluctant to seek help. Interventions that address work-life balance and increase access to support are urgently needed in academic medical centers.

Retrospective descriptive analysis of an urban pediatric collaborative care program.

OBJECTIVE: The prevalence of mental health conditions in pediatric patients in the United States is approximately 15%. Concerningly, nearly half go untreated, with lower treatment rates among children of color. Collaborative care can increase access to care and has an emerging evidence base for pediatrics. We present retrospective results from a collaborative care program that accepted referrals for a variety of conditions. METHODS: Pediatric patients seen in an academic, urban collaborative care program from July 2019 to December 2021 were tracked in a registry. Demographics, presenting problem(s), symptoms, treatment, and discharge dispositions were examined. Descriptive data were analyzed, including changes in reported symptoms via paired t-tests. RESULTS: Three hundred nineteen patients were seen. Racial and ethnic diversity in our clinic's population was similar to that of the surrounding community, with half belonging to a minoritized racial or ethnic group. Symptom comparisons demonstrated clinically and statistically significant improvements from intake to discharge. CONCLUSION: Collaborative care can improve access to care and outcomes for a diverse pediatric population. Our clinic served racial and ethnic patient populations that were representative of the demographics of the metropolitan area. Further study is necessary to determine if collaborative care increases access for these underserved groups.

Catatonia: A Narrative Review for Hospitalists.

Background: Catatonia is a complex psychomotor syndrome commonly associated with psychiatric disorders. However, hospitalists encounter this condition on medical floors, where it is typically due to an underlying medical, especially neurological, etiology. Delays in the diagnosis of catatonia are common and lead to worsened outcomes for patients, including a multitude of medical complications, such as venous thromboembolism and stasis ulcers. Catatonia due to a medical condition is less likely to respond to benzodiazepine therapy; identification and treatment of the underlying cause is crucial. Methods: This article provides a practical review of the catatonia literature, with a focus on diagnosis, workup, and management of catatonia for patients admitted to medical hospitals. Conclusions: With greater knowledge about catatonia, internists are uniquely positioned to recognize and initiate treatment.

Against Medical Advice Discharge: A Narrative Review and Recommendations for a Systematic Approach.

Approximately 1%-2% of hospitalizations in the United States result in an against medical advice discharge. Still, the practice of discharging patients against medical advice is highly subjective and variable. Discharges against medical advice are associated with physician distress, patient stigma, and adverse outcomes, including increased morbidity and mortality. This review summarizes discharge against medical advice research, proposes a definition for against medical advice discharge, and recommends a standard approach to a patient's request for discharge against medical advice.