A&E Abstracts and Extracts

Authors: Juliana Zambrano, MD, et al.

Abstract: Research into racial and ethnic disparities in Psychiatry has hitherto focused on the availability and utilization of mental health services; care in emergency departments; and inpatient psychiatric services. Little is known about disparities in care within general hospital C-L Psychiatry services.

In this study, the authors conducted a retrospective chart review using electronic health record data of all adults (≥ 18 years) admitted to inpatient medical or surgical floors at Massachusetts General Hospital for whom a psychiatric consultation was requested from March 1 to April 30, 2021.

They examined differences by race and ethnicity in the rates of consultation requests; psychiatric diagnoses made by both primary teams and the psychiatric consultants; use of legal holds or restraints; use of psychotropic medications; follow-up by the C-L Psychiatry service; and ultimate disposition.

The service received 310 unique consults during the study period. Compared to hospital-wide numbers, Black-identifying patients were over-represented in the sample (11.9% vs 6.6%), while Latinx patients were underrepresented (6.1% vs 9.8%).

For Black-identifying patients, there were higher odds of being placed on a legal hold both prior to, and after, the consult question; and in having a one-to-one observer prior to, and after, the initial consult visit. But there were no other measurable differences in care or outcomes by racial or ethnic categories.

“Black-identifying patients may be more likely to receive psychiatric consultation and be placed on legal holds because of a combination of chronic adverse social determinants of health and race-based bias,” conclude the authors. “Conversely, Latinx patients may be less likely to receive psychiatric consultation because of language barriers, among other factors.”

They add: “The lack of disparities identified in other domains may be encouraging, but larger studies are needed. Further research is also needed to identify causality and interventions that could help close the gap in care and outcomes for racial and ethnic minorities.”

Importance: A growing body of research describes how exposure to adverse social determinants of health drives poor health outcomes. In the US, people of color have repeatedly endured health inequities, including increased morbidity and mortality, and decreased access and quality of care. And over the past several years, there has been an increasing recognition of and focus on individual, institutional, and systemic racism and its impacts on health disparities.

At a clinical level, implicit racial and ethnic bias has been shown to be prevalent among health care professionals and has been related to differing provider-patient interactions, acute care, diagnostic and treatment decisions, chronic disease management, and ultimate health outcomes. Many institutional guidelines, health care delivery, and broader national policies and practices have also been historically racist and thought to be causal of health disparities.

As the authors say, multidisciplinary services such as C-L Psychiatry may be particularly important to characterize as they exemplify an interplay of many factors in patient and team encounters. Chronic socioeconomic disparities, our medical and surgical colleagues' clinical judgment and care, and the psychiatrist's ability to gather information and make independent decisions, blend with each other—and with all clinicians' unconscious attitudes.

Availability: Pre-publication in General Hospital Psychiatry.

Authors: David Fipps, DO, et al.

Abstract: Phosphatidylethanol (PEth) is a serum biomarker that can detect alcohol use within the last 28 days with excellent sensitivity and specificity. Urinary ethyl glucuronide (uEtG) is commonly used in transplant settings to screen for alcohol use; however, it has several limitations relevant to liver transplantation. Transplant centers are beginning to regularly utilize PEth as part of the screening process for high-risk liver transplantation candidates, though, say the authors, the clinical utility of uniform pre-transplant PEth testing is unclear.

Therefore the authors reviewed all patients evaluated for liver transplantation from December 2019 through May 2022 at a large academic tertiary referral center utilizing uniform serum PEth and uEtG screening.

In patients with a positive PEth, they examined whether the result would have been detected with uEtG, leading to a change in the Psychosocial Assessment of Candidate for Transplantation (PACT) score.

From their sample of 865 individuals, 48 were found to have a positive PEth and in 47.91% of these cases the positive PEth identified alcohol use missed by a concomitant uEtG screen.

Importance: As the authors say, in a significant number of liver transplant candidates, pre-transplant PEth screening at the time of initial evaluation identified alcohol use that would have been missed by uEtG testing. Moreover, PEth would have identified discrepancies from the patient's self-report, and influenced clinical decision making. These findings support the use of uniform PEth screening in liver transplantation evaluations.

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

Authors: Maryland Pao, MD, FACLP, et al.

Abstract: This review tracks current training pathways for pediatric C-L Psychiatry.

Significant workforce shortages of child and adolescent psychiatrists (CAP) over the past three decades have led to the creation of new training pathways between pediatrics and CAP training programs to care for children whose medical and psychiatric management has become increasingly complex.

Several options are now available to receive excellent training in pediatric C-L Psychiatry, say the authors. “Efforts to foster continued interactions and shared education between adult and pediatric C-L Psychiatry providers are likely to be beneficial to both disciplines given the astonishing advances in technology over the years that have allowed many patients with complex childhood medical disorders to survive into adulthood today.”

While general C-L Psychiatry programs have grown significantly over recent decades, there is currently only one one-year ACGME C-L Psychiatry fellowship program approved for pediatric C-L Psychiatry training—at Albert Einstein College of Medicine at Montefiore Children’s Hospital and Medical Center (nine months in pediatric C-L Psychiatry and three months in adult C-L Psychiatry)—and no dedicated fellowship or board certification specific to pediatric C-L Psychiatry.

Multiple pathways exist for those interested in working at the intersection of pediatrics, CAP and C-L Psychiatry. No pathway is categorically ‘right’, say the authors—each takes a different amount of time, provides the trainee with different certification options, and allows for different opportunities for future roles, such as becoming a training director in C-L Psychiatry or CAP.

Importance: How do we increase the numbers of pediatric C-L Psychiatry providers against a prolonged background of workforce shortages? This review encapsulates the variety of training pathways available to those looking to specializes in pediatric C-L Psychiatry.  

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

Authors: Natalia Tesli, PhD, et al

Abstract: Conduct disorder (CD), a common mental disorder in children and adolescents, is characterized by antisocial behavior. CD has been shown to precede a range of adult-onset mental disorders.

In this study, the authors interrogated comorbidity between CD and other mental disorders from the Norwegian Mother, Father and Child Cohort Study and investigated how polygenic risk scores for mental health traits were associated with CD/CD traits in childhood and adolescence.

Gene-environment interplay patterns for CD were explored with data on bullying and parental education. The authors found CD to be comorbid with several child and adult-onset mental disorders.

Importance: In this large, population-based cohort study of children in Norway, comorbidity patterns, genetic and environmental risk factors for CD, and CD-related traits were explored. The main results were a widespread pattern of associations between CD and child- and adult-onset mental disorders, as well as associations between genetic risk scores for child- and adult-onset mental disorders and CD diagnosis/CD traits.

Availability: Pre-publication in Psychiatry Research.

 

Authors: Patrick Ryan, BA, Office of the Clinical Director, National Institute of Mental Health, et al.

Abstract: Medically ill adults are at elevated risk for suicide. Chronic pain and hopelessness are associated with suicide; however, few studies have examined the interaction between chronic pain and hopelessness in predicting suicide risk among hospitalized adults.

This study of 720 patients—a secondary analysis of a multisite study to validate the Ask Suicide-Screening Questions (ASQ) among adult medical inpatients—describes the association between chronic pain, hopelessness, and suicide risk (defined as recent suicidal ideation or lifetime suicidal behavior) as well as the interaction between chronic pain and hopelessness.

Importance: Significant associations are shown between chronic pain and suicide risk; and hopelessness and suicide risk. Future research should examine the temporality and mechanisms underlying these relationships to inform prevention efforts for medically ill adults.

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