A&E Abstracts and Extracts

Authors: Patrick Triplett, MD, et al.

Abstract: In some settings, it is impractical to integrate a proactive consultation service into every hospital unit. On-request and proactive services are likely to coexist in the future, say the authors.

This report describes differences between contemporary proactive and on-request services within the same academic medical center, comparing demographic and clinical data collected retrospectively from a four-year period from the electronic medical record.

Proactive service saw four times as many patients as on-request patients at admission (7,592 vs. 1,762), but transitions and handoffs between services were common, with 434 admissions involving both services, comprising nearly 20% of the on-request service's total contacts.

Proactive service admissions had a shorter length of stay and a faster time to first psychiatric contact. There were more than three times as many admissions to psychiatry from the proactive service. The on-request service's admissions had a longer length of stay, were much more likely to involve intensive care unit services, surgical services, and transfers among units, and the patients seen were more likely to die in the hospital or to be discharged to subacute rehabilitation.

Overall, results suggest that the two services fulfill complementary roles, with the proactive service's rapid screening and contact providing care to a high volume of patients who might otherwise be unidentified and underserved. Simultaneously, the on-request service's ability to manage patients in response to consult requests over a much larger area of the hospital provided important support and continuity for patients with complex health needs.

“Institutions revising their consultation services will likely need to consider the best balance of these differing functions to address perceived demand for services,” say the authors.

Importance: As the authors say, even large, multispecialty institutions will seldom have the capacity to integrate psychiatric consultation services into every hospital unit. On-request services may serve as ‘safety nets’ for psychiatric services in such institutions on floors without embedded, proactive teams. They cover a large area of the hospital, often with fewer personnel, and may also be tasked with covering emergencies or urgent consults on the proactive floors when the proactive teams are limited or not available.

Therefore, it is important to understand not only the process of change from on-request to proactive consultation models but also the interactive roles these services may play in the same institution, particularly as clinicians and institutional leaders must decide on what services to implement in what settings.

In this study, work of proactive and on-demand service models in a single hospital was found to overlap and serve complementary roles.

Availability: Pre-publication in the Journal of the Academy of Consultation-Liaison Psychiatry (JACLP).

Authors: Marianne Côté-Olijnyk, et al.

Abstract: The number of forcibly displaced people has more than doubled over the past decade. Many people fleeing are left in limbo without a secure pathway to citizenship or residency.

This review reports the prevalence of mental disorders in migrants living in limbo, the association between limbo and mental illness, and the experiences of these migrants in high-income countries.

The authors searched electronic databases for quantitative and qualitative studies published after January 1, 2010, on mental illness in precarious migrants living in high-income countries and performed a meta-analysis of prevalence rates.

Fifty-eight articles met inclusion criteria. The meta-analysis yielded prevalence rates of 43% for anxiety disorders; 49.5% for depression; and 40.8% for posttraumatic stress disorder.

Having an insecure status was associated with higher rates of mental illness in most studies comparing migrants in limbo to those with secure status.

Six themes emerged from the qualitative synthesis: the threat of deportation, uncertainty, social exclusion, stigmatization, social connection, and religion.

“Clinicians should take an ecosocial approach to care that attends to stressors and symptoms,” say the authors. “Furthermore, policymakers can mitigate the development of mental disorders among migrants by adopting policies that ensure rapid pathways to protected status.”

Rates for PTSD, depression, and anxiety disorders were higher than hitherto reported rates among refugees.

The number of forcibly displaced migrants reached 108 million in 2022, having doubled over the last 10 years, according to United Nations High Commissioner for Refugees. The number of asylum applications increased to 16.2 million over the last decade. In addition, 10 to 15 per cent of 214 million international migrants are undocumented.

Forced displacement occurs when individuals are forced to leave their home as a result of armed conflict, organized violence, human rights violations, or disasters. Asylum seekers are individuals seeking protection in a new country whose bid for refuge has not yet been adjudicated. In contrast, a refugee is someone who has been granted international protection according to Article 1 of the Geneva Convention.

Some migrants may also be characterized as undocumented or irregular when they lack official legal status in a country. This may occur after a failed refugee claim, overstaying a visa, or a myriad of other reasons.

“Many migrants live in a state of protracted uncertainty because of the impermanence of their immigration status and the threat of deportation,” say the authors.

Importance: Previous systematic reviews have examined the prevalence of mental illness in asylum seekers and refugees combined, sometimes also including internally displaced persons. While these studies have produced important data on the mental health of forced migrants, they often fail to discriminate between legal categories of migrants. Thus, some have argued that future research should look at data according to migration status, as this study does, to ascertain the impact of specific psychosocial and legal circumstance.

Limbo in high-income countries appears to deprive migrants their sense of safety, likely exacerbating past trauma or other forms of social exclusion that determine mental health. While clinicians cannot change the pre-migratory experiences of displaced people, they should advocate for conditions that provide greater security in the host country, say the authors.

And they add: “We should not forget that limbo is produced rather than inevitable.”

Availability: Published by Psychiatry Research.

Authors: Mascha van’t Wout-Frank, PhD, et al.

Abstract: Can therapeutic exposure using virtual reality (VR) be augmented with simultaneously applied transcranial direct current stimulation (tDCS) to reduce symptoms of posttraumatic stress disorder (PTSD)?

That was the question posed in a clinical trial involving 54 US military veterans with warzone-related trauma enrolled from April 2018 to May 2023 at a secondary care Department of Veterans Affairs hospital and included one- and three-month follow-up visits.

tDCS delivered during VR exposure significantly improved self-reported PTSD symptoms, reduced measures of autonomic arousal, and improved social functioning compared with sham stimulation during VR exposure.

Participants were presented with 12 VR events that started with a low-intensity experience of riding in a mine-resistant, ambush-protected vehicle, through escalating exposure, including 0.50-caliber burst, and road ambushes. Participants repeated the same eight-minute VR scenario three times over approximately 25 minutes with approximately 30 seconds between scenarios to check how participants tolerated the experience.

The trial demonstrated the potential of combined tDCS and VR for PTSD treatment—yielding clinically meaningful improvements in an otherwise difficult-to-treat patient population. “This reflects an important step forward in the use of combined brain stimulation and contextual control, and underscores the innovative capability of these technologies,” say the authors.

Importance: These findings suggest that the use of combined VR exposure plus tDCS could be a promising treatment for warzone-related PTSD—a common psychiatric disorder that is particularly difficult to treat in military veterans. Non-invasive brain stimulation has significant potential as a novel treatment to reduce PTSD symptoms.

Availability: Published by JAMA Psychiatry.

Authors: Alexander Sahm, MSc, et al.

Abstract: Persistent somatic symptoms are regularly explained using a cognitive-behavioral model (CBM). In the CBM, predisposing, perpetuating, and precipitating factors are assumed to interact and to cause the onset and endurance of somatic symptoms. However, these models are rarely investigated in their entirety.

The authors conducted an online-survey of 2,114 German participants during the COVID-19 pandemic. Participants completed questionnaires that measured different factors of the CBM.

Importance: Findings from the study support the CBM model, suggesting it as suitable to explain bodily symptoms in the general population and to possibly guide clinical practice.

Availability: Published by Psychosomatic Medicine.

Authors: Karl Aaltonen, MD, PhD, et al.

Abstract: What are the immediate and long-term risks and risk factors for suicide after hospitalization for patients with depression, and are there factor-specific, time-dependent risks?

In this study of 193,197 hospitalizations among 91,161 individuals for depression in Finland from 1996 to 2017, patients hospitalized for depression had extremely high risk of suicide in the first days after discharge, with seven factors modifying overall risk manyfold. The relative risk of each factor showed diverging temporal patterns, being constant, declining, or increasing.

Discharged patients with depression form a very high-risk group for immediate suicide, say the authors, with the risk influenced by several factors with characteristic temporal patterns of observed potency.

The authors set out to examine the absolute risk and risk factors for suicide in hospitalized patients with depression starting from the first days after discharge up to two years and to evaluate whether the size of relative risk by factor displays temporal patterns over consecutive phases of follow-up.

“Although we found a decreasing trend over time, the high-risk, post-discharge period still requires intensified attention,” say the authors. “Contributing factors and targets for prevention could include a treatment failure, low response to treatments chosen, delays in response, or insufficiently identified risk during admission.

“Patients may conceal their intentions in the last appointments before death, and unplanned or patient-initiated discharges are risk factors for post-discharge suicide. Continuity of care and access to enhanced psychiatric outpatient care within days of discharge should be imperative.”

Importance: Discharged patients with depression form a very high-risk group for immediate suicide, the risk being the highest over the first post-discharge days. Several factors modify the very high short-term risk.

Availability: Published by JAMA Psychiatry.