Top Ten Tips Palliative Care Clinicians Should Know About the Physical Manifestations of Psychiatric Illness and Treatment.

Addressing the psychiatric aspects of serious illness in palliative care (PC) is crucial to both care delivery and outcomes. Psychiatric comorbidities are common among patients with PC needs and can significantly impact their total burden of symptomatic distress, overall quality of life, functional independence, and healthcare utilization. Yet, these aspects of care are often deferred to mental health consultant teams in the context of busy PC services and often limited human resources. To provide comprehensive and person-centered care, PC clinicians must understand the interplay between medical conditions and psychiatric presentations within a biopsychosocial framework to respond empathically, efficiently, and effectively. This article is the first of a two-part series developed in collaboration with a group of psychiatric-palliative care specialists. This article explores ten common physical manifestations of psychiatric illness and treatment among patients facing serious illnesses. The second article will provide pragmatic tips PC clinicians should know about the psychiatric manifestations of nonpsychiatric serious illness and treatment. Combined, these two articles support a holistic approach that PC clinicians can use to prioritize and integrate both mental and emotional well-being throughout the continuum of serious illness.

Top Ten Tips Palliative Care Clinicians Should Know About the Psychiatric Manifestations of Nonpsychiatric Serious Illness and Treatments.

Mental health issues are widespread and significant among individuals with serious illness. Among patients receiving palliative care (PC), psychiatric comorbidities are common and impact patient quality of life. Despite their prevalence, PC clinicians face challenges in effectively addressing the intricate relationship between medical and psychiatric disorders due to their complex, intertwined and bidirectionally influential nature. This article, created collaboratively with a team of psychiatric-palliative care experts, is the second in a two-part series examining the bidirectional relationship between medical and psychiatric illness in PC. This article explores 10 prevalent psychiatric manifestations associated with severe illness and its treatment. Building upon the first article, which focused on 10 common physical manifestations of psychiatric illness among patients receiving PC, these two articles advocate for an integrated approach to PC that prioritizes mental and emotional wellbeing across the continuum of serious illness.

Grief in Medical Students: The Short and Long-Term Impacts on Health and Well-Being.

CONTEXT: Healthcare workers often experience grief stemming from the loss of patients under their care. The impact of personal grief on healthcare workers' wellbeing is less well described, particularly for trainees. To better characterize the prevalence and impact of personal grief on the mental and physical health of medical students, we conducted a survey of medical students at our institution. METHODS: An electronic Qualtrics survey was distributed to all currently enrolled medical students at our institution. After an initial question screening for loss before or during medical school, our survey assessed (1) basic demographic data; (2) relationship to the deceased; (3) impact of the loss on trainee health; and (4) utilization of institutional supports for grief. RESULTS: A total of 344 (68.8%) students responded to our survey. Two hundred and 25 (65.4%) students had experienced personal loss prior to or during medical school. 53.7% experienced more than 1 loss, with most of these losses (62.5%) occurring more than 2 years prior to the survey date. Up to 40% of respondents reported at least 1 psychologically distressing symptom that persisted beyond 1 year. Most students (93.8%) relied on family members for support; however, 23.2% of students indicated they would use institutional resources if available. CONCLUSION: Most medical students have experienced bereavement before or during medical school, which has had significant impact on their well-being. While medical students did not typically utilize institutionally based resources, many students expressed interest in such resources.

COVID-19-associated psychosis: A systematic review of case reports.

OBJECTIVES: To describe the comorbidities, presentations, and outcomes of adults with incident psychosis and a history of COVID-19. METHODS: We completed a descriptive systematic review of case reports according to PRISMA guidelines, including cases of adult patients with incident psychosis and antecedent or concurrent COVID-19. We extracted patient demographics, comorbidities, clinical course, and outcomes, and assessed cases for quality using a standardized tool. RESULTS: Of 2396 articles, we included 40 reports from 17 countries, comprising 48 patients. The mean age of patients was 43.9 years and 29 (60%) were males. A total of 7 (15%) had a documented psychiatric history, 6 (13%) had a substance use history and 11 (23%) had a comorbid medical condition. Delusions were the most common (44 [92%]) psychiatric sign and psychosis lasted between 2 and 90 days. A total of 33 (69%) patients required hospitalization to a medical service and 16 (33%) required inpatient psychiatric admission. The majority (26 [54%]) of cases did not assess for delirium and 15 (31%) cases were judged to be of high risk of bias. CONCLUSIONS: Despite the growing awareness of COVID-19's association with incident psychosis at a population level, cases of COVID-19-associated psychosis often lacked clinically relevant details and delirium was frequently not excluded. PROSPERO registration number: CRD42021256746.

Top Ten Tips Palliative Care Clinicians Should Know About Bereavement and Grief.

Palliative care (PC) focuses on caring for the whole person, from birth to death, while managing symptoms and helping to navigate medical complexities. Care does not stop at the time of death, however, as assisting patients, families, and fellow clinicians through grief and bereavement is within PC's purview. Unfortunately, many clinicians feel unprepared to deal with these topics. In this article, PC and hospice clinicians define and explain bereavement, distinguish normative grief from pathological grief, offer psychometrically sound scales to screen and follow those suffering from grief, and discuss the interaction between grief and bereavement and the physical and mental health of those who are left behind after the death of a loved one.

Opioid-induced Somatic Activation: Prevalence in a Population of Patients With Chronic Pain.

Context and objective Opioids have heterogeneous side effects including a well-known effect of sedation; however, the opposing effect of stimulation, or somatic activation, has been largely ignored or overlooked. The objective of this study is to determine the prevalence of opioid-induced somatic activation (OISA). Methods We conducted a retrospective chart review of 189 patients seen by a single clinical psychiatrist/pain specialist. During the initial encounter, the clinician took a standardized history of every opioid currently or previously taken by the patients, and enquired if the patients had experienced a somatically activating or sedating effect per opioid. Results Patients recalled an average exposure to 5.1 opioids (SD: 1.9). Ninety-one patients (48.1%; mean: 1.6) reported somatic activation, while 118 (62.4%; mean: 1.7) reported sedation from at least one opioid. Fifty-eight patients (30.7%) identified at least one opioid as activating, and another as sedating. The distribution of OISA did not significantly differ by gender, race, primary pain diagnosis, or depression. The distribution of OISA by oxycodone significantly differed compared to morphine sulfate (27.3% vs 8.9%; p: 0.005), while sedation did not (29.0% vs 24.3%; p: 0.46). Conclusions In this study, we quantified the previously unstudied phenomenon of OISA. This phenomenon appears dependent on opioid type with some opioids, such as oxycodone, appearing more likely to have this effect. Given current concerns about the risks of opioids in high-risk populations, future studies are needed to study this phenomenon to arrive at an accurate determination of the potential risks and benefits of OISA.

Top Ten Tips Palliative Care Clinicians Should Know About Psychopharmacology.

Palliative care (PC) providers often prescribe psychotropic medications to address psychological and physical suffering of patients with serious medical illness. Consideration must be given to the significant medical comorbidities of the patient when selecting a medication. This article seeks to provide guidance on how to safely and effectively select a psychotropic agent for depression, anxiety, and other distressing symptoms for patients with serious illness. To do so, we draw upon a team of physicians and a pharmacist with training in psychiatry and PC to highlight the "Top 10" tips for selecting a psychotropic medication to provide relief for patients with serious medical illness.

The effects of written emotional disclosure and coping skills training in rheumatoid arthritis: a randomized clinical trial.

OBJECTIVE: Two psychological interventions for rheumatoid arthritis (RA) are cognitive-behavioral coping skills training (CST) and written emotional disclosure (WED). These approaches have developed independently, and their combination may be more effective than either one alone. Furthermore, most studies of each intervention have methodological limitations, and each needs further testing. METHOD: We randomized 264 adults with RA in a 2 × 2 factorial design to 1 of 2 writing conditions (WED vs. control writing) followed by 1 of 2 training conditions (CST vs. arthritis education control training). Patient-reported pain and functioning, blinded evaluations of disease activity and walking speed, and an inflammatory marker (C-reactive protein) were assessed at baseline and 1-, 4-, and 12-month follow-ups. RESULTS: Completion of each intervention was high (>90% of patients), and attrition was low (10.2% at 12-month follow-up). Hierarchical linear modeling of treatment effects over the follow-up period, and analyses of covariance at each assessment point, revealed no interactions between writing and training; however, both interventions had main effects on outcomes, with small effect sizes. Compared with control training, CST decreased pain and psychological symptoms through 12 months. The effects of WED were mixed: Compared with control writing, WED reduced disease activity and physical disability at 1 month only, but WED had more pain than control writing on 1 of 2 measures at 4 and 12 months. CONCLUSIONS: The combination of WED and CST does not improve outcomes, perhaps because each intervention has unique effects at different time points. CST improves health status in RA and is recommended for patients, whereas WED has limited benefits and needs strengthening or better targeting to appropriate patients.

Pain catastrophizing and pain-related fear in osteoarthritis patients: relationships to pain and disability.

This study examined the degree to which pain catastrophizing and pain-related fear explain pain, psychological disability, physical disability, and walking speed in patients with osteoarthritis (OA) of the knee. Participants in this study were 106 individuals diagnosed as having OA of at least one knee, who reported knee pain persisting for six months or longer. Results suggest that pain catastrophizing explained a significant proportion (all Ps < or = 0.05) of variance in measures of pain (partial r(2) [pr(2)] = 0.10), psychological disability (pr(2) = 0.20), physical disability (pr(2) = 0.11), and gait velocity at normal (pr(2) = 0.04), fast (pr(2) = 0.04), and intermediate speeds (pr(2) = 0.04). Pain-related fear explained a significant proportion of the variance in measures of psychological disability (pr(2) = 0.07) and walking at a fast speed (pr(2) = 0.05). Pain cognitions, particularly pain catastrophizing, appear to be important variables in understanding pain, disability, and walking at normal, fast, and intermediate speeds in knee OA patients. Clinicians interested in understanding variations in pain and disability in this population may benefit by expanding the focus of their inquiries beyond traditional medical and demographic variables to include an assessment of pain catastrophizing and pain-related fear.

Pain behavior in rheumatoid arthritis patients: identification of pain behavior subgroups.

This study used Ward's minimum variance hierarchical cluster analysis to identify homogeneous subgroups of rheumatoid arthritis patients suffering from chronic pain who exhibited similar pain behavior patterns during a videotaped behavior sample. Ninety-two rheumatoid arthritis patients were divided into two samples. Six motor pain behaviors were examined: guarding, bracing, active rubbing, rigidity, grimacing, and sighing. The cluster analysis procedure identified four similar subgroups in Samples 1 and 2. The first subgroup exhibited low levels of all pain behaviors. The second subgroup exhibited a high level of guarding and low levels of other pain behaviors. The third subgroup exhibited high levels of guarding and rigidity and low levels of other pain behaviors. The fourth subgroup exhibited high levels of guarding and active rubbing and low levels of other pain behaviors. Sample 1 contained a fifth subgroup that exhibited a high level of active rubbing and low levels of other pain measures. The results of this study suggest that there are homogeneous subgroups within rheumatoid arthritis patient populations who differ in the motor pain behaviors they exhibit.

A randomized, controlled trial of emotional disclosure in rheumatoid arthritis: can clinician assistance enhance the effects?

Emotional disclosure by writing or talking about stressful life experiences improves health status in non-clinical populations, but its success in clinical populations, particularly rheumatoid arthritis (RA), has been mixed. In this randomized, controlled trial, we attempted to increase the efficacy of emotional disclosure by having a trained clinician help patients emotionally disclose and process stressful experiences. We randomized 98 adults with RA to one of four conditions: (a) private verbal emotional disclosure; (b) clinician-assisted verbal emotional disclosure; (c) arthritis information control (all of which engaged in four, 30-min laboratory sessions); or (d) no-treatment, standard care only control group. Outcome measures (pain, disability, affect, stress) were assessed at baseline, 2 months following treatment (2-month follow-up), and at 5-month, and 15-month follow-ups. A manipulation check demonstrated that, as expected, both types of emotional disclosure led to immediate (post-session) increases in negative affect compared with arthritis information. Outcome analyses at all three follow-ups revealed no clear pattern of effects for either clinician-assisted or private emotional disclosure compared with the two control groups. There were some benefits in terms of a reduction in pain behavior with private disclosure vs. clinician-assisted disclosure at the 2-month follow-up, but no other significant between group differences. We conclude that verbal emotional disclosure about stressful experiences, whether conducted privately or assisted by a clinician, has little or no benefit for people with RA.

A 1-year study of hydroxyapatite-derived biomaterials in an adult sheep model: III. Comparison with autogenous bone graft for facial augmentation.

BACKGROUND: The present study investigates onlay bone grafts and implants in a large-animal (sheep) model to determine whether there are composite biomaterials that can maximize long-term facial augmentation when compared with conventional bone grafts. METHODS: Facial augmentation was performed in 10 adult sheep. First, 16.8 x 5-mm disks were prepared from autogenous calvarial bone, hydroxyapatite ceramic, ceramic composite of 60 percent hydroxyapatite and 40 percent beta-tricalcium phosphate (60 percent hydroxyapatite ceramic), and hydroxyapatite cement paste. Facial recipient sites were the body of the mandible (depository), the maxillary region (resorptive), and the frontal bone (depository). The volume of all bone grafts and implants was determined using computed tomographic scans, and the amount of bone formation was measured by means of backscatter electron microscopy 1 year postimplantation. RESULTS: Cranial bone graft demonstrated a highly significant reduction in volume in all sites studied. Other than a slight decrease in volume of hydroxyapatite cement paste disks applied to the maxillary region, there was no significant change in volume of the biomaterials implanted in any of the remaining recipient sites. Bone replacement was greatest in hydroxyapatite ceramic (23.9 percent) followed by 60 percent hydroxyapatite ceramic (16.4 percent) and least with hydroxyapatite cement paste (4.2 percent). Minimal differences in bone replacement were noted between recipient sites. CONCLUSIONS: This study demonstrates that the volume maintenance of onlay hydroxyapatite composites is highly predictable, whereas that of cranial bone graft is unpredictable. Minimal differences were seen in bone replacement within biomaterials between "depository" and "resorptive" facial recipient sites. Ceramic forms of onlay hydroxyapatite implants demonstrated significantly greater bone replacement than did the cement paste forms of hydroxyapatite.

A 1-year study of osteoinduction in hydroxyapatite-derived biomaterials in an adult sheep model: part II. Bioengineering implants to optimize bone replacement in reconstruction of cranial defects.

The present study investigated hydroxyapatite biomaterials implanted in critical-size defects in the calvaria of adult sheep to determine the optimal bioengineering of hydroxyapatite composites to facilitate bone ingrowth into these materials. Five calvarial defects measuring 16.8 mm in diameter were made in each of 10 adult sheep. Three defects were filled with cement paste composites of hydroxyapatite and beta-tricalcium phosphate as follows: (1) 100 percent hydroxyapatite-cement paste, (2) 60 percent hydroxyapatite-cement paste, and (3) 20 percent hydroxyapatite-cement paste. One defect was filled with a ceramic composite containing 60 percent hydroxyapatite-ceramic, and the fifth defect remained unfilled. One year after implantation, the volume of all biomaterials was determined by computed tomography, and porosity and bone replacement were determined using backscatter electron microscopy. Computed tomography-based volumetric assessment 1 year after implantation demonstrated that none of the unfilled cranial defects closed over the 1-year period, confirming that these were critical-size defects. There was a significant increase in volume in both the cement paste and ceramic implants containing 60 percent hydroxyapatite (p < 0.01). There was no significant change in volume of the remaining cement paste biomaterials. Analysis of specimens by backscatter electron microscopy demonstrated mean bone replacement of 4.8 +/- 1.4 percent (mean +/- SEM) in 100 percent hydroxyapatite-cement paste, 11.2 +/- 2.3 percent in 60 percent hydroxyapatite-cement paste, and 28.5 +/- 4.5 percent in 20 percent hydroxyapatite-cement paste. There was an inverse correlation between the concentration of hydroxyapatite and the amount of bone replacement in the cement paste for each composite tested (p < 0.01). Bone replacement in 60 percent hydroxyapatite-ceramic composite (13.6 +/- 2.0 percent) was not significantly different from that in 60 percent hydroxyapatite-cement paste. Of note is that the ceramic composite contained macropores (200 to 300 microm) that did not change in size over the 1-year period. All cement paste composites initially contained micropores (3 to 5 nm), which remained unchanged in 100 percent hydroxyapatite-cement paste. Cement paste implants containing increased tricalcium phosphate demonstrated a corresponding increase in macropores following resorption of the tricalcium phosphate component. Bone replacement occurred within the macropores of these implants. In conclusion, there was no significant bone ingrowth into pure hydroxyapatite-cement paste (Bone Source, Stryker-Leibinger Inc., Dallas, Texas) in the present study. The introduction of macropores in a biomaterial can optimize bone ingrowth for reconstruction of critical-size defects in calvaria. This was demonstrated in both the ceramic composite of hydroxyapatite tested and the cement paste composites of hydroxyapatite by increasing the composition of a rapidly resorbing component such as beta-tricalcium phosphate.