A comparison of daytime and out of hour mental health presentations to Beaumont Hospital Emergency Department between 2018 and 2020.

BACKGROUND: In 2018, there were more than 12,000 self-harm presentations to emergency departments (EDs) in Ireland with 50% occurring between 7p.m. and 3a.m. There is evidence that the assessment quality and follow-up is variable across clinicians. To address this, The National Clinical Programme for the Management of Self-Harm in the ED (NCPSH 2016) was developed to set clear standards. AIM: Our aim was to compare diagnosis and management of patients presenting to Beaumont Hospital (BH) ED, across a 3-year period, by the on-site Liaison Psychiatry Service, during normal working hours, to the off-site on call service outside of normal working hours (OOH). METHODS: This is a retrospective audit of BH ED patients referred for psychiatric assessment between 2018 and 2020, using patient electronic records for data collection, and Pearson's chi square testing for group differences. Post hoc analysis was performed using adjusted residuals and Bonferroni correction. RESULTS: Of 3659 psychiatric referrals to Beaumont ED from 2018 to 2020, alcohol-related disorders were the most common diagnosis and were diagnosed more frequently during normal working hours (n = 592, 16.2%; 22.9% normal hours vs 8.5% OOH, p < 0.001), while personality disorder was diagnosed more frequently out of hours. (n = 432, 11.8%; 9.6% normal hours vs 14.4% out of hours, p < 0.001). There was a statistically significant difference in referral to voluntary services out of hours (7.2% normal hours vs 0.3% OOH). CONCLUSION: In contrast to previous findings, our study found higher rates of alcohol-related disorders diagnosed during normal hours vs OOH. Furthermore, voluntary and addiction services were under-utilised OOH and this presents an important teaching opportunity.

One year of psychiatric presentations to a hospital emergency department during COVID-19.

OBJECTIVES: To examine the impact of the first full year of the COVID-19 pandemic and its associated restrictions on the volume and nature of psychiatric presentations to an emergency department (ED) in a large academic hospital. METHODS: Anonymised clinical data on psychiatric presentations to the ED were collected for the 52-week period from the start of the COVID-19 pandemic and compared with corresponding 1 year periods in 2019 and 2018. RESULTS: There was a significant increase in psychiatric presentations overall to the ED during the first year of the COVID-19 pandemic compared to previous years, in contrast to a reduction in total presentations for all other specialties. There was a marked increase in psychiatric presentations of those below 18 years, and in the 30-39 years and 40-49 years age groups, but a decrease in the 18-29 years group. There was a significant increase in anxiety disorder presentations but a decrease in alcohol related presentations. There was no significant change observed in the rates of presentations for self-harm or suicidal ideation. CONCLUSIONS: Psychiatric presentations to the ED have increased during the first year of the COVID-19 pandemic in contrast to a decrease in presentations for other medical specialties, with this increase being driven by out-of-hours presentations. The fourfold increase in presentations of young people below the age of 18 years to the ED with mental health difficulties is an important finding and suggests a disproportionate burden of psychological strain placed on this group during the pandemic.

Anti-NMDA receptor encephalitis: an important differential diagnosis in psychosis.

We present four cases of confirmed anti-NMDA receptor encephalitis; three presented initially with serious psychiatric symptoms and the other developed significant psychiatric symptoms during the initial phase of illness. Brain biopsy findings of one patient are also described. Psychiatrists should consider anti-NMDA receptor encephalitis in patients presenting with psychosis and additional features of dyskinesias, seizures and catatonia, particularly where there is no previous history of psychiatric disorder.

Impact of changes in community psychiatric service provision on mental health presentations to the emergency department.

BACKGROUND: The reconfiguration of many Irish stand-alone psychiatric units has led to many patients in acute mental health need now being assessed in emergency departments (EDs). This has implications for ED resources and raises questions about appropriate assessment location for this group. AIMS: This report aims to examine the impact of removal of a direct community access point for patients in acute mental health need on ED presentations in a Dublin hospital. METHODS: We examined data on ED referrals to psychiatry over 5 years: 12 months before the service change, and four subsequent 12-month periods. We compared numbers referred, mode of referral, average ED length of stay, proportion with no physical issue requiring psychiatric assessment only, and numbers who did not wait for psychiatry assessment. RESULTS: In the year directly after the service change, referrals to psychiatry from ED increased by 200%, remaining at this level for the subsequent 3 years. Of these, 32.5% were referred by a GP-more than a threefold increase in numbers from the previous year, with both numbers remaining similarly elevated over subsequent years. In the year after the service change, 52.1% of total ED to psychiatry presented solely for mental health reasons-nearly a fourfold increase in cases from the previous year, and remained high. CONCLUSIONS: Removing a direct community access point for this group resulted in a substantial increase in ED presentations, many of which did not have physical needs. This study has implications for future policy to address the needs of this group, especially in light of the pandemic.

Impact of initial COVID-19 restrictions on psychiatry presentations to the emergency department of a large academic teaching hospital.

OBJECTIVES: To determine if the initial COVID-19 societal restrictions, introduced in Ireland in March 2020, impacted on the number and nature of psychiatry presentations to the emergency department (ED) of a large academic teaching hospital. METHODS: We examined anonymised clinical data of psychiatry presentations to the ED during the initial 8-week period of COVID-19 restrictions. Data from corresponding 8-week periods in 2018 and 2019 were also extracted for comparison. RESULTS: Psychiatry presentations to ED reduced by 21% during the COVID-19 restrictions, from 24/week to 19/week when compared with corresponding periods in 2018/2019 (Poisson's Rate Test estimate of difference -5.2/week, 95% CI 1.3-9.1, p = 0.012). Numbers attending for out-of-hours assessment remained unchanged (81 v. 80), but numbers seeking assessment during normal hours decreased (71 v. 114). We observed increased presentations from the <18 age group, but decreased presentations from the 18 to 29 age group (Pearson's Chi-Square 20.363, df = 6, p = 0.002). We recorded an increase in anxiety disorders during the initial COVID-19 restrictions (31 v. 23), and a reduction in alcohol disorders (28 v. 52). The proportion of presentations with suicidal ideation (SI) or self-harm as factors remained unchanged. CONCLUSIONS: Rates of emergency presentation with mental illness reduced during the initial COVID-19 restrictions. This may represent an unmet burden of mental health needs. Younger people may be experiencing greater distress and mental illness during the current crisis. More people sought help for anxiety disorders during the COVID-19 restrictions compared with corresponding data from 2018 and 2019.

An integrated multidisciplinary model of COVID-19 recovery care.

BACKGROUND: In January 2020, the WHO declared the SARS-CoV-2 outbreak a public health emergency; by March 11, a pandemic was declared. To date in Ireland, over 3300 patients have been admitted to acute hospitals as a result of infection with COVID-19. AIMS: This article aims to describe the establishment of a COVID Recovery Service, a multidisciplinary service for comprehensive follow-up of patients with a hospital diagnosis of COVID-19 pneumonia. METHODS: A hybrid model of virtual and in-person clinics was established, supported by a multidisciplinary team consisting of respiratory, critical care, infectious diseases, psychiatry, and psychology services. This model identifies patients who need enhanced follow-up following COVID-19 pneumonia and aims to support patients with complications of COVID-19 and those who require integrated community care. RESULTS: We describe a post-COVID-19 service structure together with detailed protocols for multidisciplinary follow-up. One hundred seventy-four patients were discharged from Beaumont Hospital after COVID-19 pneumonia. Sixty-seven percent were male with a median age (IQR) of 66.5 (51-97). Twenty-two percent were admitted to the ICU for mechanical ventilation, 11% had non-invasive ventilation or high flow oxygen, and 67% did not have specialist respiratory support. Early data suggests that 48% of these patients will require medium to long-term specialist follow-up. CONCLUSIONS: We demonstrate the implementation of an integrated multidisciplinary approach to patients with COVID-19, identifying those with increased physical and mental healthcare needs. Our initial experience suggests that significant physical, psychological, and cognitive impairments may persist despite clinical resolution of the infection.

Autoantibodies and Psychosis.

Research into antibody-mediated disease, in response to immune dysfunction or to tumour development, has rapidly expanded in recent years. Antibodies binding to neuroreceptors can cause psychiatric features, including psychosis, in a minority of patients as well as neurological features. The responsiveness of some of these cases to immunotherapy supports the hypothesis that antibody-associated mechanisms play a role in the pathogenesis of psychotic diseases. The purpose of this chapter is to review autoantibodies that are most likely to be relevant for patients with psychotic symptoms. Herein, we describe receptor structure and mechanism of action, clinical and psychiatric features for the growing number of neuronal surface antibodies, including those to the N-methyl-D-aspartate (NMDA) receptor. The identification of a subgroup of patients with psychiatric features having antibody-mediated disease highlights the importance of considering the diagnosis, particularly in those patients presenting with a first episode of psychosis.

Opt-Out Panel Testing for HIV, Hepatitis B and Hepatitis C in an Urban Emergency Department: A Pilot Study.

OBJECTIVES: Studies suggest 2 per 1000 people in Dublin are living with HIV, the level above which universal screening is advised. We aimed to assess the feasibility and acceptability of a universal opt-out HIV, Hepatitis B and Hepatitis C testing programme for Emergency Department patients and to describe the incidence and prevalence of blood-borne viruses in this population. METHODS: An opt-out ED blood borne virus screening programme was piloted from March 2014 to January 2015. Patients undergoing blood sampling during routine clinical care were offered HIV 1&2 antibody/antigen assay, HBV surface antigen and HCV antibody tests. Linkage to care where necessary was co-ordinated by the study team. New diagnosis and prevalence rates were defined as the new cases per 1000 tested and number of positive tests per 1000 tested respectively. RESULTS: Over 45 weeks of testing, of 10,000 patient visits, 8,839 individual patient samples were available for analysis following removal of duplicates. A sustained target uptake of >50% was obtained after week 3. 97(1.09%), 44(0.49%) and 447(5.05%) HIV, Hepatitis B and Hepatitis C tests were positive respectively. Of these, 7(0.08%), 20(0.22%) and 58(0.66%) were new diagnoses of HIV, Hepatitis B and Hepatitis C respectively. The new diagnosis rate for HIV, Hepatitis B and Hepatitis C was 0.8, 2.26 and 6.5 per 1000 and study prevalence for HIV, Hepatitis B and Hepatitis C was 11.0, 5.0 and 50.5 per 1000 respectively. CONCLUSIONS: Opt-out blood borne viral screening was feasible and acceptable in an inner-city ED. Blood borne viral infections were prevalent in this population and newly diagnosed cases were diagnosed and linked to care. These results suggest widespread blood borne viral testing in differing clinical locations with differing population demographic risks may be warranted.

A survey of breast cancer awareness and knowledge in a Western population: lots of light but little illumination.

There are conflicting data on breast cancer awareness and knowledge in specific population groups. We assessed awareness and knowledge of breast cancer in the general Irish population to identify sources of information on breast cancer and determine factors associated with knowledge and awareness of the disease. Participants (n=2355, 53% female) completed a multi-part questionnaire. Most (81%) had seen or heard something about breast cancer in the recent past and knowledge of symptoms and treatment was good overall. However, 66% of females overestimated their risk of developing disease, 88% underestimated the age at which it was most likely to develop and 56% underestimated 5-year survival. Knowledge of incidence and survival was higher in males (Odds Ratio (OR) 1.3, 95% Confidence Interval (CI); 1.1-1.5), participants with higher education (1.5; 1.2-1.7) and those who received information from television (1.3; 1.1-1.5). Ignorance regarding incidence, outcome and risk makes it unlikely that the general public or at risk females could currently make informed decisions on a range of breast cancer issues.

Anti-N-methyl-d-aspartate receptor encephalitis: review of clinical presentation, diagnosis and treatment.

Anti-N-methyl-d-aspartate (NMDA) receptor encephalitis is a form of encephalitis occurring primarily in women and associated with antibodies against NR1 or NR2 subunits of the NMDA receptor. As a potentially treatable differential for symptoms and signs seen in neurology and psychiatric clinics, clinicians practising across the lifespan should be aware of this form of encephalitis. Common clinical features include auditory and visual hallucinations, delusions, behavioural change (frequently with agitation), impaired consciousness, motor disturbance (ranging from dyskinesia to catatonia), seizures, and autonomic dysfunction. We present a review of the literature on the disorder, including its clinical presentation, differential diagnosis, epidemiology, treatment and prognosis.

Financial impact of accurate discharge coding in a liaison psychiatry service.

OBJECTIVE: Previous research has shown that patients seen by liaison psychiatry services are a complex and expensive patient group and that the psychiatric co-morbidities of hospital inpatients are poorly attested at discharge for assignment to diagnosis-related groups (DRGs). The aim of this study was to investigate the accuracy of discharge coding in a neuropsychiatry liaison population. We also aimed to establish whether or not, had the correct diagnosis been assigned, additional funding would have been allocated to the hospital. METHODS: Diagnostic codes were retrospectively collected from the discharge diagnoses for all inpatients (n=276) referred to the neuropsychiatry liaison service in a university hospital over a 12 month period and these were compared to a consensus diagnosis. Using grouper software, codes were then changed to reflect the consensus diagnoses and DRGs were recalculated to see if the change in diagnosis led to a change in reimbursement for those patients. RESULTS: Discharge diagnosis and consensus diagnosis were in agreement in 30% of cases. When discharge codes were corrected, patients changed to a higher paying DRG in 28/220 (12.7%) of patients. The increase in costing associated with this change in DRG was €305,349. CONCLUSIONS: According to these results, not only is the complexity of patients seen by psychiatry consult services in general hospitals not reflected in the discharge diagnosis, but, in this sample of patients, the additional complexity would have led to a significant increase in reimbursement to the hospital. Further training of doctors should increase awareness of this important issue.

First episode psychosis and an underlying cerebellar tumour.

We report on the case of a middle aged lady who was referred by her GP with what appeared to be a case of first episode psychosis. Following assessment and investigation an underlying cerebellar tumour was identified. Our aim is to draw attention to the ongoing debates regarding the possible role of the cerebellum in psychosis and cognition and on neuroimaging as a diagnostic modality in cases of first episode psychosis.

Expenditure of compensation from legal claims in an opiate dependent population.

This study examined the expenditure of compensation received from legal claims by service users attending an outpatient methadone programme in Dublin. Most claims (n = 62) were as a result of road traffic accidents (74%) or personal injury (15%). There were 28 reports of claims resulting in payment of compensation totalling €912,871. Of the compensation not placed in trust (€477,871), almost 40% was spent on drugs and 8% on alcohol. Of those who reported no drug misuse at the time of the compensation being paid, seven out of 11 (64%) reported subsequently spending a significant amount on substance misuse. The risks of receiving large amounts of money in this population are substantial and include initiation and exacerbation of substance misuse, and risk of overdose. Alternative ways of managing the payment of compensation should be considered for this vulnerable population.