In 2021, 7,499 cases of potential sex-trafficking were reported to the US National Human Trafficking Hotline, 28% of which involved minors. Children who have been sex-trafficked suffer from higher rates of psychiatric disorders including depression, PTSD, ADHD, bipolar disorder, and psychosis. Risk factors increasing entry into sex-trafficking include homelessness or runaway behaviors, low socioeconomic status, and presence of psychiatric or substance use disorders, among others. Recruitment is most often ‘relational’ in which traffickers enter into romantic relationships or close friendships with victims and provide them with gifts or money, which they later weaponize to coerce young people to sell sex.

The authors present the case of a 13-year-old girl with a history of depressive symptoms and suicidal ideation presented due to parental concern for risky behaviors. She endorsed depressed mood and anhedonia in the context of interpersonal stressors but denied suicidal ideation. She admitted to running away three times, for days to weeks at a time, and mentioned receiving free clothes, food, and shelter from friends.

The girl reported being sexually active with multiple partners and wanting to become pregnant. She denied being forced to have sex and became defensive when questions were raised about sexual partners and the location of where she lived when not at home.

“Sex-trafficking is rarely disclosed by the victim and hence it can be difficult to readily identify the ‘grooming’ or prodromal stages,” say the authors. “Given the positive attention and material benefits of the grooming stage, coupled with a lack of emotional maturity and life experience, youth are even more unlikely to report concerns in early signs of sex-trafficking.”

Hence, sex-trafficking may be difficult for patients and psychiatric providers to identify in the grooming stage. “Psychiatrists must be able to identify early stages of trafficking to intervene and mitigate associated psychiatric consequences,” say the authors.

Dr. Peterson: “Our patients are often vulnerable to exploitation and subsequent trauma for a variety of reasons. Thinking across the lifespan, our younger patients—particularly those with a background of neglect or trauma—are particularly at risk, and our opportunities to intervene are critical. The authors of this abstract present patterns that could allow identification of youth at risk for sex-trafficking—hopefully early enough to prevent further traumatic outcomes.”

Medically hospitalized patients experiencing homelessness (PEH) face risks at discharge resulting in poor outcomes and readmissions. Given higher rates of mental illness and substance use among PEH, C-L Psychiatry teams are often closely involved in the care of PEH. Street medicine programs support PEH after discharge by providing aftercare and linkage to outpatient services, including psychiatric treatment, though systemic barriers prevent optimal coordination with inpatient providers.

The authors’ goal was to create a pathway supporting PEH at discharge utilizing interdisciplinary care with their medical hospital’s C-L Psychiatry providers (i.e., social workers and care managers), and a community street medicine program. They conducted a stakeholder-driven needs assessment, using the data to pilot a consult mechanism facilitating warm handoffs between their hospital and street medicine providers.

Survey results show respondents encounter PEH frequently (49% stating once per week or more); practitioners feel this work is within their scope of practice (74%), and is important for good outcomes (97%).

“However, many do not feel comfortable talking to patients about homelessness (36%) and do not feel equipped to handle their needs (73%),” say the authors. “After implementation of street medicine consultation, an order was placed 21 times on 17 unique patients in a three-month span, and 64% of unique patients saw both Psychiatry and street medicine during at least one admission.”

The authors add: “We demonstrate feasibility, enthusiastic participation, and qualitative benefits of a stakeholder-driven street medicine consult mechanism championed by C-L Psychiatry and implemented at a local hospital. We will conduct a post-intervention survey to assess experiences with the pilot and explore billing opportunities to establish sustainability.”

Dr. Peterson: “C-L psychiatrists have been leaders in developing innovative models of care to reach patients more effectively in a variety of settings—critical developments in the current health care climate where access to quality psychiatric care is limited. The authors describe a pilot program to reach undomiciled patients with a street-medicine consultation model of care. This work is a reminder of the importance of Social Determinants of Health in holistic patient care, and of the value of C-L psychiatrists in treating patients where they are, in collaboration with other medical providers.”

Post-acute sequelae of SARS-CoV-2 (PASC), characterized by persistent clinical symptoms four weeks after the onset of the acute infection, affect approximately 10-30% of patients. PASC symptoms are variable and can lead to significant physical and emotional difficulties. There is a relationship between severity of somatic symptoms and psychological distress.

The aim of this study was to compare responses to measures of somatic symptoms, and psychological perceptions of symptoms, among patients with a history of COVID-19 (with/without PASC). This is a sub-analysis of a longitudinal study of the medical sequelae of COVID-19, conducted by the National Institute of Allergy and Infectious Diseases.

Patients with PASC reported significantly higher rates of somatic symptoms and psychological distress regarding their symptoms, supporting existing research that patients who have persistent COVID-19 symptoms experience heightened psychological distress.

“PASC are associated with a multitude of potentially debilitating symptoms, including depression and anxiety,” say the authors. “Current guidelines recommend a multidisciplinary approach, including mental health care, in the management of post-COVID-19 syndrome. C-L psychiatrists may lend additional expertise in the management of psychological distress in the context of persistent somatic symptoms.”

Dr. Peterson: “COVID-19 is no longer the immediate health crisis that it was—but continues to make its mark in health care settings. Post-COVID syndromes remain poorly understood—and recommendations for diagnosis, assessment, and treatment remain limited—despite millions of grant dollars spent. The authors present findings from a database review that will hopefully be a part of ongoing efforts to understand these conditions. The relationship of somatic disorders and post-COVID syndromes will certainly be a critical and challenging diagnostic domain for C-L psychiatrists.”

Individuals with minoritized racial and ethnic identities face inequities in access to mental health care, particularly in the perinatal period, as psychiatric disorders are a major contributor to maternal mortality. Moreover, an observed increase in perinatal psychiatric disorders during the COVID-19 pandemic further exacerbated inequities in access to mental health care for patients of color.

In this study, the authors aimed to explore the potential relationship between patients’ racial/ethnic identity and experiences when receiving psychiatric consultation services in an obstetrics hospital.

They analyzed data from 351 patients assigned female at birth with race/ethnicity extracted from medical records (White=228, African American=107, Other (American Indian, Guam/Chomorro, Other Asian, African American and White, Not Specified, Declined (to answer)=16).

They found that the average time to consultation was 1.76 days for White, 2.12 for African American, and 5.64 for ‘Other’.

They categorized reasons for consults based on disease process: internalizing (depression, anxiety, trauma-related disorders, suicidal ideation); externalizing (substance use disorders, suicide attempts), psychosis, delirium, capacity assessment, and medication management.

“No significant difference was found between individuals identifying as White or African American with internalizing diagnoses,” say the authors, “however, individuals who identified as White were significantly more likely to be given an externalizing diagnosis compared to those identifying as Black. Individuals who identified as White were also more likely to carry alcohol and substance use disorder diagnoses at discharge compared to those identifying as African American.”

The authors suggest potential reasons included individuals from minoritized populations hesitating to discuss substance use with providers due to fear related to historical injustices and systemic racism in health care, which are particularly pertinent in the perinatal period. Another possibility is providers’ own biases in referral for substance use disorder care.

Dr. Peterson: “We were pleased to again have many strong submissions to the Diversity, Equity, and Inclusion topic this year. The Program Committee working with the DEI committee included a DEI question for all abstracts. The authors of this abstract evaluated correlations between patient race/ethnicity and time to consultation and diagnosis in a women’s hospital. Their findings challenge us to look critically at our consultation data, and identify and develop strategies to resolve inequities.”

Development and Validation of the NSIT, A New Symptom Scale for Functional Neurological Disorder

Lead presenter: Mike Bushey, MD, PhD

Functional neurological disorder (FND) is characterized by neurological symptoms (i.e., deficits in motor, sensory, and/or cognitive function) not caused by underlying structural neurological damage. The range of symptoms reported by patients with FND has been a barrier to the development of measures to assess symptom severity and track response to therapy. The authors report their experience with a flexible instrument developed to assess and track FND symptoms.

Their Indiana University Somatic Disorders Clinic specializes in the treatment of somatic disorders, especially FND. To assess severity of FND symptoms, they developed the Neurological Symptom Impact Tracker (NSIT), which asks respondents to list up to three neurological symptoms that have occurred over the past year into a free text field. For each symptom reported, frequency is assessed with a 0-3 Likert scale (‘none, several days, every day, multiple times/day’), and intensity is assessed with a 0-2 Likert scale (‘mild’, ‘moderate’, ‘severe’).

To assess preliminary validation of their NSIT measure, the authors calculated Cronbach’s alpha to assess internal scale validity, and Pearson’s correlations between measures to assess construct validity.

“Measures to assess FND symptoms are lacking,” say the authors. “Our preliminary validation of the NSIT measure shows promise as a potential tool allowing quantitative assessment of FND symptoms and their interference and suggests a fully powered validation study of the NSIT would be warranted.”