Advancing Models of Care in Transplant Psychiatry: A Review and Considerations for Enhancing the Multidisciplinary Approach.

PURPOSE OF REVIEW: Psychosocial considerations in transplant candidacy evaluation, waitlist, and post-transplant period is tremendously important to overall transplant care. Integration of mental health services in multidisciplinary transplant teams improves adherence to medical regimens, enhances quality of life, and reduces the risk of post-transplant complications. RECENT FINDINGS: Despite this, psychiatrists are often under-utilized by transplant centers, with engagement typically limited to transplant candidacy evaluations or reactive consults in a traditional CL model. In this review, we aim to 1) highlight the relevance of psychiatry throughout the transplant course, 2) outline the role of a CL psychiatrist in advancing patient care and supporting multidisciplinary teams in transplant, 3) develop an understanding of CL service models in both the inpatient and ambulatory setting and 4) consider the utility of innovating current transplant psychiatry practices.

Palliative Care Psychiatry: Building Synergy Across the Spectrum.

PURPOSE OF REVIEW: Palliative care (PC) psychiatry is a growing subspecialty focusing on improving the mental health of those with serious medical conditions and their caregivers. This review elucidates the current practice and ongoing evolution of PC psychiatry. RECENT FINDINGS: PC psychiatry leverages training and clinical practices from both PC and psychiatry, addressing a wide range of needs, including enhanced psychiatric care for patients with serious medical illness, PC access for patients with medical needs in psychiatric settings, and PC-informed psychiatric approaches for individuals with treatment-refractory serious mental illness. PC psychiatry is practiced by a diverse workforce comprising hospice and palliative medicine-trained psychiatrists, psycho-oncologists, geriatric psychiatrists, other mental health professionals, and non-psychiatrist PC clinicians. As a result, PC psychiatry faces challenges in defining its operational scope. The manuscript outlines the growth, current state, and prospects of PC psychiatry. It examines its roles across various healthcare settings, including medical, integrated care, and psychiatric environments, highlighting the unique challenges and opportunities in each. PC psychiatry is a vibrant and growing subspecialty of psychiatry that must be operationalized to continue its developmental trajectory. There is a need for a distinct professional identity for PC psychiatry, strategies to navigate administrative and regulatory hurdles, and greater support for novel clinical, educational, and research initiatives.

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.

Understanding the Landscape of Consultation Liaison Psychologists in Academic Medical Centers.

Current literature lacks data related to the role of psychologists on consultation-liaison (CL) services; previous data indicates only 4% of CL services are run by psychologists, while 32% of liaison mental health services include a psychologist. As CL psychologists' roles within hospitals grow, it is critical to identify clinical strategies and organizational structures of CL services across hospital systems. The current study seeks to provide a deeper understanding of CL psychologists' scope of work. Participants (N = 77) (15% response rate) completed a measure developed for this study, exploring psychologist roles, clinical practice, and departmental structures. Thirty-two percent of respondents were in Psychiatry Departments, 58% were in academic medical centers, almost half had training programs and the most frequently utilized billing code was: Given the limited data available, this study provided a contemporary and foundational understanding of the CL psychologist roles as well as future avenues of empirical inquiry such as discrete organization and structural characteristics.

Management of High Acuity Patients in Pediatric Medical Settings: The Role of Consultation/Liaison Psychologists During the Growing Mental Health Crisis.

Since the onset of the COVID-19 pandemic, consultation/liaison (C/L) psychologists had to drastically shift their practices to care for psychiatrically acute pediatric patients admitted to medical settings. The aim of the current study was to provide an updated state of the field surrounding these changes and their implications for clinical practice. Psychologists and psychology post-doctoral fellows completed an anonymous, 51-item survey distributed via a national professional organization listserv. The results review responses, by percentages, about C/L team composition and practice patterns, as they relate to suicide risk assessments, transfers to inpatient psychiatric and other levels of care, intervention for boarding patients, and disposition and safety planning. Thematically coded qualitative responses regarding impact and management of high acuity patients are also summarized. The state of the field outlined by this survey suggests an increase in C/L assessments and interventions delivered to pediatric patients with acute psychiatric needs, as well as a reverberating effects on provider wellness. Ensuring providers establish competency for this subset of patients is vital to the continued provision of optimal patient care and to sustained provider wellness. Considerations for the field are explored.

A survey of the psychiatric care provided for children and young people in general hospital settings in New Zealand.

OBJECTIVE: The aim of this study was to conduct an in-depth survey of psychiatric care provided for children and young people (CYP) in general hospital settings in New Zealand (NZ). METHOD: As part of a larger national survey of Consultation-Liaison Psychiatry (CLP) services across the lifespan, a 44-question survey was emailed to clinicians who were involved in providing psychiatric care for CYP at each of the 24 public general hospitals with specialist paediatric services. RESULTS: Responses were obtained from all four paediatric CLP teams that cover the four specialist children's hospitals, and 16 of the 23 child and adolescent community mental health services that provide hospital inreach. These services were found to be under-resourced, utilise variable service models, and rely heavily on inreach. CONCLUSION: Escalating presentation rates for young people and increasingly complex paediatric presentations pose major challenges for the psychiatric care of CYP in general hospital settings. Utilising international staffing standards and service models, proposals are made to evolve more consistent and effective paediatric CLP services in NZ.

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.

Comorbid psychiatric disorders and long-term survival after liver transplantation in transplant facilities with a psychiatric consultation-liaison team: a multicenter retrospective study.

OBJECTIVE: Comorbid psychiatric disorders negatively affect the survival rate of patients with some physical disorders. In liver transplant recipients, various psychiatric disorders have been identified as worsening prognosis. However, little is known about how the presence of any comorbid (overall) disorders affect the survival rate of transplant recipients. In this study, we examined the effect of overall comorbid psychiatric disorders on survival rate in liver transplant recipients. METHODS: A total of 1006 recipients who underwent liver transplantation between September 1997 and July 2017 across eight transplant facilities with a psychiatric consultation-liaison team were identified consecutively. Recipients were categorized into those with comorbid psychiatric disorders and those without comorbid psychiatric disorders. In the comorbid psychiatric disorder group, psychiatric disorder diagnosis and time of diagnosis were investigated retrospectively. RESULTS: Of the 1006 recipients, 294 (29.2%) had comorbid psychiatric disorders. Comorbid psychiatric disorders in the 1006 recipients were insomnia (N = 107, 10.6%), delirium (N = 103, 10.2%), major depressive disorder (N = 41, 4.1%), adjustment disorder (N = 19, 1.9%), anxiety disorder (N = 17, 1.7%), intellectual disability (N = 11, 1.1%), autism spectrum disorder (N = 7, 0.7%), somatic symptom disorder (N = 4, 0.4%) schizophrenia (N = 4, 0.4%), substance use disorder (N = 24, 2.4%) and personality disorder (N = 2, 0.2%). The most common time of psychiatric disorder diagnosis was within the first 3 months after liver transplantation (51.6%). The final mortality in patients with comorbid psychiatric disorder diagnosis during the five periods (pretransplant, transplant to 3 months, months to 1 year, 1 to 3 years, and over 3 years posttransplant) was 16.2%, 18.8%, 39.1%, 28.6%, and 16.2% respectively, and there were no significant differences between the five periods (χ2 = 8.05, df = 4, p = 0.09). Overall comorbid psychiatric disorders were significantly associated with shorter survival time (log-rank test: p = 0.01, hazard ratio: 1.59 [95% confidence interval: 1.14-2.21], survival rate at the endpoint [%]: 62.0 vs. 83.3). However, after adjusting for confounding variables using Cox proportional hazards regression, there was no significant effect of overall comorbid psychiatric disorders on prognosis. CONCLUSION: Comorbid psychiatric disorders did not affect the survival rate of liver transplant recipients in this study.

Psychiatric service delivery for older people in hospital and residential aged care: An updated systematic review.

OBJECTIVE: To review studies reporting on the effectiveness of psychiatry service delivery for older people and people with dementia in hospital and residential aged care. METHODS: A systematic search of four databases was conducted to obtain peer-reviewed literature reporting original research published since June 2004 evaluating a psychiatry service for older people (aged 60 years and over) or people with dementia in inpatient or residential aged care settings. RESULTS: From the 38 included studies, there was consistent low-to-moderate quality evidence supporting the effectiveness of inpatient older persons' mental health wards (n = 14) on neuropsychiatric symptoms, mood, anxiety and quality of life. Inpatient consultation/liaison old age psychiatry services (n = 9) were not associated with improved depression, quality of life or mortality in high-quality randomised studies. However, low-quality evidence demonstrated improved patient satisfaction with care and reduced carer stress. The highest quality studies demonstrated no effect of psychiatric in-reach services to residential aged care (n = 9) on neuropsychiatric symptoms but a significant reduction in depressive symptoms among people with dementia. There was low-quality evidence that long-stay intermediate care wards (n = 6) were associated with reduced risk for dangerous behavioural incidents and reduced costs compared to residential aged care facilities. There was no effect of these units on neuropsychiatric symptoms or carer stress. CONCLUSIONS AND IMPLICATIONS: The scarcity of high-quality studies examining the effectiveness of old age psychiatry services leaves providers and policy-makers to rely on low-quality evidence when designing services. Future research should consider carefully which outcomes to include, given that staff skill and confidence, length of stay, recommendation uptake, patient- and family-reported experiences, and negative outcomes (i.e. injuries, property damage) are as important as clinical outcomes.

A framework for the implementation of consultation-liaison psychiatry from the characteristics of psychosomatic consultations at a general hospital in China.

OBJECTIVE: To describe the characteristics of a consultation-liaison psychiatry (CLP) service at a general hospital in China, compare the literature on CLP in other hospitals in China and abroad, and identify reasons for the differences. METHODS: The medical records of all inpatients who received liaison consultations in the first year of the establishment of Xi'an International Medical Center Hospital were reviewed. Demographic data, specific department, number of consultations, reasons for consultation, outcome of consultation, and follow-up information on patients was collected. RESULTS: A total of 630 patients were enrolled during the first year of the hospital's opening, of which 45.2% were male and 54.8% were female. A total of 89.2% of non-psychiatric departments requested a psychosomatic consultation. The percentage of middle-aged and elderly patients was 75.6%, of whom 61.6% were aged 45 to 74 years. The internal medicine department requested the highest number of consultations (48.2%), including those from respiratory medicine (12.1%), neurology (12.1%), gastroenterology (12.1%), and cardiology (12.1%). Among surgical patients, orthopedic patients (6.5%) comprised the majority of consults. The main reasons for requesting a psychosomatic consultation were depressive symptoms (139 cases, 22.8%), anxiety symptoms (137 cases, 22.5%), sleep problems (111 cases, 18.2%), and hallucinations, delusions, or behavioral problems (68 cases, 11.2%), accounting for a total of 74.6% of consultations (455/630). CONCLUSION: A significant gap exists between the level of CLP services in China and developed regions in Europe and the United States, mainly due to low psychiatric consultation rates and poor quality CLP services.

Pediatric Consultation-Liaison Psychology: Insights and Lessons Learned During the COVID-19 Pandemic.

COVID-19 has presented a variety of challenges to the provision of psychology services. In the first month of the pandemic, pediatric consultation-liaison (CL) psychologists reported significant changes in methodology of service delivery (Steinberg et al. in Clin Pract Pediatr Psychol 9:1, 2020). To better understand how and if these changes persisted, as well as other emerging trends, a follow-up study examined changes and challenges six months into the pandemic. An anonymous questionnaire assessed topics related to pediatric CL psychology including practice changes, perception of changes, and institutional support. The questionnaire was sent to the APA Society of Pediatric Society's special interest group listservs. Thirty responses were analyzed. Quantitative results showed participants' beliefs that telemedicine is equally efficacious to in-person services for outpatient psychological care, but less effective for inpatient care. Participants reported their perception of how institutions supported their safety, psychology trainee safety and training goals, and patient care. Qualitative results demonstrated that most psychologists experienced changes related to their dynamics with medical teams, which included changes in team efficiency, workload, transition, and team collaboration.

Broadening the state of play - the second national survey of Consultation-Liaison Psychiatry services in New Zealand, 2021.

OBJECTIVE: The original national survey of Consultation-Liaison Psychiatry (CLP) services in New Zealand (NZ) that was undertaken in 2018 (CLPSNZ-1) established a baseline but was limited in scope. The aim of the current study was to conduct a more in-depth national survey. METHOD: A 44-question survey was emailed to clinicians at each of the 16 general hospitals in NZ with specialist adult CLP services in 2021. RESULTS: Responses were obtained from all 16 CLP services. These services were found to be under-resourced (with mean total full-time equivalents of 0.26 psychiatrists and 1.10 clinicians per 100 inpatient beds, respectively), operate with highly variable service models (with major variations in operating hours and coverage of age groups, the Emergency Department and outpatients) and provide a predominantly consultation service. CONCLUSION: While many of the findings from CLPSNZ-1 remain relevant, the current survey has extended our understanding of the circumstances, achievements and challenges of this psychiatric subspecialty in NZ.

A survey of the psychiatric care provided for medically ill older adults in general hospitals in New Zealand.

OBJECTIVE: The aim of this study was to conduct an in-depth survey of the psychiatric care provided for medically ill older adults in general hospitals in New Zealand (NZ). METHOD: As part of a larger survey of Consultation-Liaison Psychiatry (CLP) services for all ages in NZ (CLPSNZ-2), a 44-question survey was emailed to clinicians who were involved in providing psychiatric care for medically ill older adults at each of the 16 general hospitals with designated CLP services. RESULTS: Responses were obtained from 22 services at 16 hospitals - 14 CLP services and eight Psychiatry of Old Age (POA) in-reach services. These services were found to be under-resourced, operate with highly variable service models, and predominantly provide inpatient consultations. Services could be conceptualised as six prototypes with variations of POA in-reach to hospitals, scope of CLP cover and collaboration between services. CONCLUSION: The heterogeneity in the psychiatric care for medically ill older adults in NZ means that there is an urgent need to develop more consistent CLP service models that better serve the specialist needs of older adults, and establish the policies, resources and standards needed to support them.

Clinical audit of the Consultation-Liaison psychiatric service of a metropolitan hospital.

OBJECTIVE: The primary objective of this study was to use clinical indicators to track changes in efficiency of a Consultation-Liaison service as part of a clinical audit cycle. METHODS: This was a clinical audit cycle. The auditing phase involved measuring the efficiency of the service. The 'intervention' was simply the team's awareness and involvement in tracking these statistics. Subsequently, these indicators were re-audited. RESULTS: In the initial audit cycle, 315 referrals to the C-L service were audited over a 3 month period, showing a 24 hour time-to-seen rate of 80% and a 36 hour time-to-seen rate of 89.2%. Upon re-auditing of 112 referrals following our intervention, 24 hr timeliness had risen to 92% and 36 hr timeliness had risen to 96.4%. CONCLUSION: The measuring of clinical indicators of efficiency in C-L may give service improvement personnel a reflection of the functionality of a C-L service. By involving team members in the measuring and tracking of these indicators, we may be able to boost overall clinical efficiency and outcomes.

Evaluation of consultation liaison psychiatry in Australian public hospitals (AU-CLS-1).

OBJECTIVE: This study aimed to determine whether consultation liaison psychiatric service (CLS) staffing within Australian public hospitals meet national and international minimum staffing standards. METHOD: Semi structured interviews were conducted with CLS Directors across Australia from August to December 2021. Data were collected on demographics, staffing, funding, hospital size and admissions. RESULTS: The majority of services did not meet minimum standards for CLS staffing. Non-medical staff outnumbered medical staff with increasing rurality. Psych-oncology CLS had the greatest resources, skill mix and service breadth. CONCLUSION: Although CLS are heterogeneous, most services are inadequately resourced to provide baseline specialist mental health care in Australian hospitals. Establishing national minimum standards for CLS staffing will facilitate uniform service development and quality care provision.

A Cross-Sectional, Retrospective, and Comparative Study between Delirium and Non-Delirium Psychiatric Disorders in a Psychogeriatric Inpatient Population Referred to Consultation-Liaison Psychiatry Unit.

Background and objectives: Delirium is the most prevalent psychiatric disorder in inpatient older people. Its presence is associated with higher rates of institutionalization, functional disability and mortality. This study aims to evaluate delirium in a hospitalized psychogeriatric population, focusing on which factors predict the appearance of delirium, the impact it generates and the diagnostic concordance between non-psychiatric physicians and psychiatrists. Material and methods: This is an observational, cross-sectional, retrospective, and comparative study. We obtained data from a sample of 1017 patients (≥65 years) admitted to general hospital and referred from different services to the consultation-liaison psychiatry (CLP) unit. Logistic regression was performed using delirium as the dependent variable. To estimate the concordance of the diagnoses, the Kappa coefficient was used. To assess the impact of delirium, an ordinal regression, Wilcoxon median test and Fisher's test were performed. Results: Delirium is associated with a higher number of visits, OR 3.04 (95% CI 2.38-3.88), longer length of stay and mortality, OR 2.07 (95% CI, 1.05 to 4.10). The model to predict delirium shows that being >75 years old has an OR of 2.1 (95% CI, 1.59-2.79), physical disability has an OR of 1.66 (95% CI, 1.25-2.20), history of delirium has an OR of 10.56 (95% CI, 5.26-21.18) and no use of benzodiazepines has an OR of 4.24 (95% CI, 2.92-6.14). The concordance between the referring physician's psychiatric diagnosis and the psychiatrist CLP unit showed a kappa of 0.30. When analysing depression and delirium, the concordance showed Kappa = 0.46. Conclusions: Delirium is a highly prevalent psychiatric disorder, but it is still underdiagnosed, with low diagnostic concordance between non-psychiatric doctors and psychiatrists from CLP units. There are multiple risk factors associated with the appearance of delirium, which must be managed to reduce its appearance.

Consultation-Liaison Psychiatry-From Theory to Clinical Practice: an Observational Study in a Psychiatric Unit in the General Hospital of Perugia.

BACKGROUND: Subjects suffering from psychiatric disorders are frequently hospitalized due to medical comorbidities. In the present study, we analyzed consultation-liaison psychiatry (CLP) activity in a General Hospital, describing the sociodemographic, diagnostic, and therapeutic characteristics of the evaluated subjects, as well as reasons for consultation requests. SUBJECTS AND METHODS: Data concerning psychiatric consultation performed at the Perugia General Hospital during a 1-year period (01/06/2022-20/06/2023) were collected and analyzed by means of descriptive statistics. RESULTS: A total of 707 psychiatric consultations were performed. The primary reason that led to psychiatric consultations was psychomotor agitation. 85 (18.5%) patients attempted suicide; the most frequent modality was the assumption of drugs at non-therapeutic doses. The 72% of the sample (n=509) presented a clear-cut medical comorbidity. In most cases, subjects were referred to Community Mental Health and Addiction services (n=22, 32.4%). CONCLUSIONS: CLP plays a crucial role in the perspective of the overall well-being of hospitalized subjects, but also for the overall management of complex cases. Despite this, a homogeneous approach with standardized guidelines is needed in this field.

FACTORS ASSOCIATED WITH NON-ATTENDANCE TO OUTPATIENT CONSULTATION-LIAISON PSYCHIATRY APPOINTMENTS: A RETROSPECTIVE COHORT STUDY.

BACKGROUND: Non-attendance to outpatient mental health appointments is associated with adverse clinical and financial outcomes. The aim of this study was to investigate the rates of non-attendance to outpatient Consultation-Liaison Psychiatry (CLP) appointments and the factors associated with non-attendance. SUBJECTS AND METHODS: Retrospective cohort study, including two groups of data: 950 initial and 3503 follow-up appointments between 01/01/2015 and 31/12/2019. We employed descriptive statistics, parametric/non-parametric tests and logistic regression analysis. We used a range of environmental, socio-demographic and service-related characteristics as independent parameters and non-attendance as the dependent parameter. RESULTS: Initial and follow-up non-attendance rates were 27.5% and 18.8% respectively. Opting-out text message reminders was associated with both initial and follow-up non-attendance. Higher education was associated with initial non-attendance, whereas lower education with follow-up non-attendance. Other factors associated with non-attendance to initial appointments were: English being the participant's primary communication language, having an appointment with a psychiatrist as opposed to a trained nurse or Cognitive Behavioural Therapist, and longer waiting time. Follow-up non-attendance was also associated with younger age, shorter driving distance and higher income/employment. CONCLUSION: We suggest that improving opt-in rates through a combination of staff and patient education and promotion, improving waiting lists, reducing the stigma associated with seeing a psychiatrist, but also perhaps targeting different socio-economic groups of patients with different strategies should be the focus of policy making to tackle non-attendance. Further research into patient-related and environmental factors, such as day of the week, driving distance, language of primary communication, education, income and employment is warranted in order to design more effective policies and improve engagement with CLP, but also psychiatric services in general.

Prevalence of collusion in cancer communications: A meta-analysis.

INTRODUCTION: Collusion is the non-disclosure of information about diagnosis or prognosis, frequently encountered in cancer care and palliative services. Unraveling collusion is a skill and differences among communication techniques by Health Care Workers have maintained the process of non-disclosure to patients and caregivers. Identifying the prevalence of collusion in cancer care is required to improve the existing strategies across the world. METHODS: A systematic review of the literature from 1991 to 2020 in the English language was conducted with the protocol registration on PROSPERO ID (CRD 42021249216.) to identify the pooled prevalence of collusion. RESULTS: By using random effect model, the pooled prevalence estimate among patients for the diagnostic and prognostic collusion was 24.15, (95% CI [17.09; 32.96], Tou2 = 1.0801, I2  = 97.9%, Cochran's Q = 1058.22, df = 21, p-value < 0.001) and 37.92, (95% CI [22.46; 56.30], Tou2 = 1.9641, I2  = 98.6%, Cochran's Q = 944.26, df = 13, p-value < 0.001) respectively. There was no difference across subgroups with different types of setting for the interview, WHO regions and trend over the years. CONCLUSIONS: Substantial prevalence of collusion goes unnoticed in cancer care. A meaningful understanding of such a large prevalence requires inquiry into the existing communication paradigm in cancer care across the world. The findings also question the need of formulating uniform interview techniques and structured assessment tools or questionnaires in cancer care to improve the disclosure rates.

Patient Satisfaction with a Psychology Consultation-Liaison Service at an Academic Medical Center.

One to two-thirds of all medically admitted patients have comorbid psychiatric concerns. To address the cognitive, behavioral, and emotional factors that affect medical hospitalization, psychological or psychiatric consultation-liaison (CL) services are consulted. The current study was designed to understand patient satisfaction with a CL psychology service and how it was associated with satisfaction with overall hospitalization, taking into consideration relevant factors. Adults medically admitted to an academic teaching hospital (N = 220), who were seen at least once by the CL psychology service, completed satisfaction and demographic questionnaires. Most patients reported being satisfied with the CL psychology service, with women reporting higher satisfaction than men. Satisfaction with the CL psychology service was associated with satisfaction with overall hospitalization, but did not differ based on age, race/ethnicity, education, income, length of stay, number of visits, or presence of psychiatric diagnosis. The results suggest that CL psychology services may contribute to improving overall patient experience.