Design and Implementation of a Regional Inpatient Psychiatry Unit for Patients who are Positive for Asymptomatic SARS-CoV-2.

BACKGROUND: Patients with psychiatric illnesses are particularly vulnerable to highly contagious, droplet-spread organisms such as SARS-CoV-2. Patients with mental illnesses may not be able to consistently follow up behavioral prescriptions to avoid contagion, and they are frequently found in settings with close contact and inadequate infection control, such as group homes, homeless shelters, residential rehabilitation centers, and correctional facilities. Furthermore, inpatient psychiatry settings are generally designed as communal spaces, with heavy emphasis on group and milieu therapies. As such, inpatient psychiatry services are vulnerable to rampant spread of contagion. OBJECTIVE: With this in mind, the authors outline the decision process and ultimate design and implementation of a regional inpatient psychiatry unit for patients infected with asymptomatic SARS-CoV-2 and share key points for consideration in implementing future units elsewhere. CONCLUSION: A major takeaway point of the analysis is the particular expertise of trained experts in psychosomatic medicine for treating patients infected with SARS-CoV-2.

A diversified approach for PKU treatment: routine screening yields high incidence of psychiatric distress in phenylketonuria clinics.

OBJECTIVES: Individuals with phenylketonuria (PKU) treated early and continuously are reported to have psychiatric and executive function impairments. The feasibility of screening for psychiatric distress and executive function impairment in individuals with PKU was tested in 3 separate clinics in North America. METHODS: Individuals were offered screening for psychiatric distress using the Pediatric Symptom Checklist, the PSC-Youth Report or the Brief Symptom Inventory and executive function impairment using the Behavior Rating Inventory of Executive Function. Gender, age and blood phenylalanine (Phe) concentrations obtained most recently and during the 2 years prior to screening were assessed. RESULTS: More than 90% of patients with PKU accepted the screening for psychiatric distress during their routine clinic visit. The screening took 15-20 min. 32% of patients screened positive for psychiatric distress and 19% for executive function impairment. More individuals >18 years screened positive for psychiatric distress while a similar number screened positive for executive function impairment across age groups. Lower blood Phe levels correlated with negative screening for psychiatric distress. Patients positive for psychiatric distress had higher (p=0.009) median and most recent blood Phe values (p=0.05). DISCUSSION/CONCLUSIONS: Routine screening for psychiatric distress of patients with phenylketonuria could be easily implemented in current clinic structures. High incidences of positive screens reinforce the need for regular psychiatric assessments of individuals with PKU. Identification and referral to local mental health providers might help to improve the standard of care for individuals with PKU.

A neuropsychiatric perspective of phenylketonuria I: overview of phenylketonuria and its neuropsychiatric sequelae.

Phenylketonuria (PKU) is an autosomal recessive metabolic genetic disorder that is associated with neuropsychiatric sequelae of varying severity. The natural history, epidemiology, and a history of the medical understanding and approaches to treatment of PKU are presented. Neurocognitive and neuropsychiatric sequelae of patients with untreated, early-treated, and continuously-treated PKU are described, and possible mechanisms for the symptoms are proposed. The authors propose an integrated approach to management of patients with PKU.

A neuropsychiatric perspective of phenylketonuria II: needs assessment for a psychiatric presence.

BACKGROUND: Phenylketonuria (PKU) is a neuropsychiatric disease with a genetically transmitted metabolic etiology. A large percentage of untreated, early-treated, and continuously treated patients with PKU suffer from neurocognitive and neuropsychiatric sequelae. To our knowledge, this is the first survey of the mental health needs of persons with PKU and availability of referral and treatment for this population. METHODS: A targeted, web-based survey was sent to 100 PKU clinics across the United States. Follow-up e-mails were sent to nonresponders. RESULTS: Thirty-four clinics responded; 56% of responding clinics reported that cognitive issues impaired patients' ability to obtain regular treatment and that screening for cognitive impairment at the clinics varied in scope and format. Clinic screening for cognitive and psychiatric issues are reported, as well as referral practices. DISCUSSION: The authors propose an integrated model for both medical and mental health care of the patients, analyze perceived barriers to screening and referral for cognitive impairment, and discuss the limitations of the survey results.

Impact of psychiatric disorders on the HIV epidemic.

Mental illness continues to fuel the HIV epidemic. There is a high prevalence of mental disorders in the HIV-infected population and a high prevalence of HIV infection in the mentally ill. Without effective treatment of mental disorders, HIV treatment outcome is poor, and transmission of disease continues. High frequencies of mental illness are found in corrections facilities, among the homeless, among injection drug users, and in patients attending sexually transmitted disease clinics. Such populations must be targeted for effective mental health treatment if overall outcomes of HIV treatment are to be improved and transmission of HIV is to be reduced. This article summarizes a presentation on mental illness and the HIV epidemic made by Andrew F. Angelino, MD, at the 10th Annual Ryan White HIV/AIDS Program Clinical Update in June 2007.

Issues in co-morbid severe mental illnesses in HIV infected individuals.

Patients with comorbid HIV and serious mental illnesses pose particular difficulties for clinicians. Presentation of several mental disturbances can be similar, and often significanlty complicate the management of advancing HIV disease. In this article, we will review the assessment and management of four serious mental conditions in HIV-infected patients: delirium, dementia, schizophrenia and bipolar disorder.

Content of advance directives for individuals with advanced dementia.

OBJECTIVE: To examine how people with end-stage dementia have conveyed their wishes for end-of-life care in advance directives. METHOD: The documents of 123 residents of three Maryland nursing homes, all with end-stage dementia, were reviewed. RESULTS: More years of education and White race were significantly associated with having an advance directive. With the exceptions of comfort care and pain treatment, advance directives were used primarily to restrict, not request, many forms of care at the end of life. Decisions about care for end-stage conditions such as Alzheimer's dementia are less often addressed in these documents than for terminal conditions and persistent vegetative state. DISCUSSION: For advance directives to better reflect a person's wishes, discussions with individuals and families about advance directives should include a range of care issues in the settings of terminal illness, persistent vegetative state or end-stage illness. These documents should be reviewed periodically to make certain that they convey accurately the person's treatment preferences.

Interrelation between psychiatric disorders and the prevention and treatment of HIV infection.

Psychiatric disorders, particularly major depression, have a profound affect on the use of and adherence to highly active antiretroviral therapy (HAART) among patients with human immunodeficiency virus (HIV) infection. Because some of the symptoms of HIV infection are similar to those of major depression, efforts to diagnose and treat major depression are further complicated. Moreover, major depression increases vulnerability to HIV infection by provoking high-risk behaviors, and it interferes with a patient's ability to comply with protocols for the prevention and treatment of HIV infection. HIV infection itself can disguise, help initiate, or exacerbate major depression. In this report, the interrelation between major depression and HIV infection is evaluated, the impact of this interrelation on adherence to HAART is described, and methods for effective treatment of psychiatric conditions in HIV-infected persons are discussed.

Training in psychosomatic medicine: a psychiatric subspecialty recognized in the United States by the American board of medical specialties.

Psychosomatic Medicine (PM) is a subspecialty of Psychiatry approved by the American College of Graduate Medical Education (ACGME) in 2003. Since its approval, subspecialty training programs in PM have been created in the United States. Training programs are designed to educate trainees in the psychiatric care of the complex medically ill, and are centered around development of certain core competencies by trainees. Completion of an ACGME-accredited training program in PM allows the graduate to sit for the PM subspecialty board examination. Development of centers with academic PM programs will lead to an increase in the depth of knowledge about the care of the complex medically ill with psychiatric comorbidities, and may thus lead to improved medical outcomes for this population. There are also individual benefits to subspecialty training in PM. In addition, there are barriers to extended postgraduate training that may require systems-level interventions to overcome.

Integrated opioid use disorder and HIV treatment: rationale, clinical guidelines for addiction treatment, and review of interactions of antiretroviral agents and opioid agonist therapies.

Injection drug use (IDU) is an important vector of HIV infection in the United States. Many patients with HIV infection have comorbid substance use disorders. Integrated treatment for HIV and substance use disorders has been shown to improve HIV and other health outcomes, but significant barriers to integrated treatment exist. For individuals who are dependent on injection opioid drugs, agonist therapies of methadone or buprenorphine maintenance are available as part of a treatment program. Patients who are infected with HIV and require antiretroviral therapy (ART) are at risk for drug-drug interaction between ART and methadone or buprenorphine. We present a programmatic approach to the evaluation and treatment of opioid use disorders for HIV care providers, as well as a summary of the available knowledge of interactions of methadone and buprenorphine with ART, along with the level of evidence for each actual or potential interaction. Based on the available information of practice and the level of clinical significance of drug-drug interactions, we conclude that buprenorphine-based maintenance treatment for opioid dependent patients is the preferred maintenance therapy for integrated treatment systems.

Update on mental health issues in patients with HIV infection.

HIV infection remains a major world health problem more than 20 years after discovery of the virus. Mental disorders make individuals more vulnerable to behaviors that transmit HIV and interfere with HIV treatment adherence. The evidence supporting the need for optimal provision of mental health care in HIV clinics is mounting, along with evidence that these disorders can be treated successfully. Disorders of mental life include brain diseases (eg, depression, bipolar disorder, schizophrenia, and dementia), personality disorders, addictions, and psychologic disruptions, which contribute to the spread of the virus through their influence on behavior. However, although evidence exists that successful treatment of co-occurring mental disorders leads to improved HIV outcomes, integrated mental health care in HIV clinics remains grossly suboptimal.

Evidence-informed assessment and treatment of depression in HCV and interferon-treated patients.

More than 4 million people are currently infected with Hepatitis C an RNA virus that may ultimately result in complete hepatic failure and is often a silent infection until late in the course of disease. Hepatitis C patients have increased rates of major depression (as well as substance abuse) and treatment of hepatitis with interferon, the current standard treatment, provokes episodes of depression in as many as a third of patients treated. Immune-dysfunction mediated mechanisms for the depression in these patients have been proposed and have increasing experimental support. The resulting depression has interfered with treatment for many patients, but several standard treatments for depression have been shown to be effective in patients with interferon-associated depression, suggesting that this should not be a barrier to effective treatment. In this paper, we review the evidence for associations between depression and Hepatitis C and interferon treatment, as well as the evidence supporting an immune mechanism for the association, and finally the data showing effective treatment and recommendations for prophylactic use of anti-depressants.

Depression and Adjustment Disorder in Patients With HIV Disease.

Depressive symptoms are common in patients with HIV disease, reflecting in part the contribution of preexisting depressive illness to risk behaviors for acquisition of HIV infection. Depression complicates management of HIV disease by increasing the likelihood of nonadherence to antiretroviral treatment regimens. HIV-infected patients with depressive symptoms may also be more likely to engage in behaviors that put others at risk of infection. These issues and approaches to diagnosis and treatment of depression in HIV-infected patients were discussed by Andrew F. Angelino, MD, at the Clinical Pathway of the Ryan White CARE Act 2002 All Grantee Conference held in Washington, DC, in August 2002.