A&E Abstracts and Extracts

Authors: Daniel McFarland, DO, et al.

Abstract: Hospitalized patients with cancer face pivotal decisions that will affect their cancer care trajectory and quality of life, but frequently lack decision making capacity (DMC). Standardization is conspicuously missing for inpatient oncology teams and for C-L psychiatrists performing DMC assessments for patients with cancer.

This study sought to characterize a single institutional experience of psychiatric consultations to assess DMC.

The authors conducted a retrospective chart review of 97 consecutive psychiatric consultations for DMC from 2017-2019. Demographic, hospital-based, and psychiatry consult differences were assessed based on the reasons for DMC evaluation (uncertainty, patient refusal, emergency) and whether patients had decisional capacity.

Of the 97 consultations, 56 (59%) hospitalized patients with cancer were unable to demonstrate capacity. Consultations came from medical services almost exclusively. Only 5% of primary teams documented their own DMC evaluation.

Only 22% of DMC evaluation by C-L psychiatrists documented four determinates of DMC. Few commented on reversibility or tenuousness of DMC, and the identification of agents/surrogates; however, psychiatry consultants were more likely to follow up on patients without DMC.

Given the substantial heterogeneity in the documentation of DMC evaluations in this review, the authors call for more rigor and standardization in documentation of DMC evaluations.

The study highlights inconsistent patterns in the determination of DMC. “A consistent approach to DMC is integral to patient-centered, ethical care,” say the authors, “especially when considering (potentially) vulnerable patient populations.

“Standardization allows for improvement even while allowing for variation based on divergent types of clinical scenarios.”

Importance: The authors describe a case to illustrates a DMC assessment where the C-L  psychiatrist is instrumental in illustrating the scope of the DMC. In patients with cancer, decisional incapacity is already high regardless of additional factors predictive of decisional incapacity. Cancer care must consider DMC alongside the cancer trajectory, especially when patients are most vulnerable during hospitalization.

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

Authors: Heather Huang, MD, et al.

Abstract: To date, there has been limited data on factors associated with meaningful engagement in collaborative care programs. So the authors set out to identify the proportion of patients who were meaningfully engaged and to investigate the factors associated with meaningful engagement in a collaborative care program.

They collated data from 6,437 patients in a collaborative care program across 27 adult primary care clinics and concluded that the presence of systematic case reviews between the behavioral health care manager and the consultant psychiatrist were highly associated with meaningful engagement. “Core principles, including regularly scheduled systematic case reviews, should be pursued,” they say.

The collaborative care model adopted in the program involves a primary care physician/advance practice provider identifying patients with psychiatric diagnoses and connecting them to the behavioral health care manager and consultant psychiatrist.

The care manager utilizes problem-solving treatment and behavioral activation strategies to address the patient's symptoms while meeting weekly with the consultant psychiatrist. Treatment recommendations are prescribed and managed by the primary care physician.

The model uses a registry to manage a caseload of patients within the primary care setting to improve patient access and outcomes while reducing health care costs.

“Studies demonstrate the model's effectiveness in treating mental health disorders and its ability to reduce health care disparities in access, quality, and outcomes,” say the authors. “With an emphasis on proactive follow-up, this model requires routine interaction between patients and the collaborative care team.”

Importance: As the authors say: “Understanding how collaborative care programs can meaningfully engage patients will be central to improving outcomes.”

Availability: Published by the Journal of the Academy of Consultation-Liaison Psychiatry (JACLP).

Authors: Alyssa Rheingold, PhD, et al.

Abstract: What are the risk factors for and prevalence rates and co-occurrence of grief-related psychiatric conditions among bereaved adults in the US?

In this study of 2,034 adults, presumptive prevalence rates of 20% for prolonged grief disorder (PGD), 34% for posttraumatic stress disorder (PTSD), and 30% for major depressive disorder (MDD) were observed among 1,529 bereaved respondents. Comorbidities were also common, as reported by 29% of respondents. The risk of grief-related psychiatric conditions was greatest among those who experienced the traumatic loss of a psychologically close individual.

“Given that loss is a risk factor for the co-occurrence of PGD, PTSD, and MDD, these findings suggest that transdiagnostic treatment may be most efficient and effective,” say the authors.

In this study, the majority of bereaved adults did not meet presumptive criteria for PGD, PTSD, or MDD. Nevertheless, PGD, PTSD, and MDD were highly prevalent and comorbid, particularly among those who experienced traumatic loss. These findings underscore the need for integrated psychological care that leverages transdiagnostic mechanisms of evidence-based practice, say the authors.

Compared with bereaved individuals with a history of losses due to natural causes, those with a history of traumatic losses were twice as likely to have a positive screening result for PGD, PTSD, and MDD.

Moreover, the proportion of individuals with a positive screening result for multiple conditions was nearly twice as high in the traumatic loss group compared with natural and no-loss groups.

Importance: Rates of grief-related psychiatric conditions, such as prolonged grief disorder, posttraumatic stress disorder, and major depressive disorder among bereaved adults in the US have been hitherto largely unknown.

Availability: Published by JAMA Network.

Authors: Maria Gonsalves Schimpf, MA, MT-BC, et al.

Abstract: Presented is the case of a physician who engages with a peer response team and discloses suicidal ideation—while himself seeing patients in the hospital. The authors provide guidance for this clinical case based on their experience and a review of available literature.

Key teaching topics include a general approach to suicide risk assessment; peer response programs for health care workers; and ethical and clinical considerations in treating colleagues.

“C-L psychiatrists should be familiar with suicide risk management, take a proactive approach to addressing modifiable risk factors, and keep in mind unique challenges of treating colleagues referred for care,” say the authors.

Importance: The Centers for Disease Control and Prevention reports that “health workers face a mental health crisis.” Harassment, shortages, and burnout among health care staff are at historic highs. Burnout among physicians and nurses has been especially prevalent since the COVID-19 pandemic.

Effective interventions for reducing burnout described in the study include job redesign, workload management, staff education, and mindfulness-based practice interventions.

Dr. B, the physician who disclosed suicidal thoughts, benefitted from one such evidence-based intervention—a hospital-based peer support program. These programs are staffed by fellow health care workers and may offer in-person or telephone-based supportive contacts.

Ethical and legal considerations in treating health care providers are also considered in the study by another physician. He says: “As physicians, maintaining our own wellness and seeking appropriate care when necessary is a professional obligation. We must help our colleagues do likewise. When there is concern that a physician is impaired and potentially dangerous to themselves or their patients, physicians hold a collective duty to our patients to ensure that the impaired physician receives care.”

The authors add: “C-L psychiatrists can engage with local efforts to support health care staff, such as by supporting peer response teams or other workforce wellness interventions. C-L psychiatrists are experts in evaluation of suicide risk across diverse settings—unfortunately, this expertise must sometimes be extended in the service of healers themselves.”

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

Authors: Isabella Raasthøj, MD, et al.

Abstract: Coping has been suggested as a perpetuating factor for physical symptoms. The aim of this study was to examine the use of coping strategies, resignation, and diversion in individuals with multiple physical symptoms according to the construct of Bodily Distress Syndrome (BDS).

The study was part of a nationwide web-based survey, Danish Symptom Cohort. In total, 100,000 individuals were invited to participate. A total of 35,810 respondents were included in this particular study, of which 8,512 (23.8%) fulfilled the criteria for having multiple physical symptoms.

This group had lower coping scores on approach and higher coping scores on resignation and diversion compared with a non-BDS group. The regression analyses showed that high scores on approach were associated with a lower probability of having multiple symptoms, whereas high scores on diversion and resignation were associated with a higher probability of having multiple symptoms.

“The study supports the hypothesis that experiencing multiple physical symptoms is associated with certain coping strategies,” say the authors.

Importance: This study is the first to examine overall coping in a large population-based sample.

Availability: Published by the Journal of Psychosomatic Research.