A&E Abstracts and Extracts

Authors: David Fipps, DO, et al.

Abstract: Adverse Childhood Experiences (ACE)—the experiences of childhood abuse and household dysfunction—are associated with the development of negative health behaviors and medical illness.

ACE’s association with poor health outcomes has been well documented in the general population; however, this relationship remains less clear in liver transplant (LT) recipients. The aims of this study were to determine the prevalence of ACE and the influence of ACE on LT outcomes.

A retrospective electronic medical record review of all LT recipients over 11 years at an academic liver transplant center resulted in a cohort comprising just over 24%, of 1,172 LT recipients, with a history of ACE. They had a higher prevalence of hepatitis C and higher pre-transplant BMI; a higher prevalence of mood, anxiety, PTSD; and a higher prevalence of alcohol use (including higher incidence of recorded relapse to alcohol post-transplant), as well as cannabis use disorders.

The authors conclude that one-quarter of LT recipients have experienced ACE: “This population may benefit from increased/improved access to appropriate mental health and substance use services, and support in the peri- and post- transplant period.”

Importance: ACE are estimated to cost the North American health care system $748 billion each year. Although the association between ACE and adverse health outcomes has been well documented, this relationship remains unstudied for certain medical populations, and specifically liver transplant recipients—a group who are vulnerable to multimorbidity.

With increasing rates of transplantation, more needs to be learned about how to effectively follow-up psychosocial services to maximize long-term benefits of transplantation.

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

Authors: George Nader, medical student, Center for Addiction and Mental; Health, Toronto, et al

Abstract: The authors formulated a predictive model that significantly predicts violence trajectories in schizophrenia based on gender and stressful life events. They identified several biological, psychological, and socioeconomic features as risk factors for violence.

They recruited 231 participants with schizophrenia spectrum disorders (SSD) at the Centre for Addiction and Mental Health, Toronto. They investigated whether the combination of developmental predictors, such as early-life adversities, personality traits, impulsiveness and resilience to stress, predict violence trajectories at specific life-stages.

“Several dispositional and environmental factors have been previously correlated with violence,” say the authors, “ however, there has been little success in assessing their ability to predict violence patterns across the lifespan. This study aims to assess violence prediction based on personality traits, psychological resilience, and life-course adversities in a non-forensic population of SSD patients."

Importance: It has long been recognized that there is an increased rate of violent behavior associated with positive symptoms of psychotic illness. For example, people with schizophrenia are four to seven times more likely to commit crimes, such as assault and homicide, and four to six times more likely to exhibit general aggressive behavior, such as verbal and physical threats, compared to the general population.

The cause of this increased rate of violence has been controversial, with some studies suggesting the increase in violence is driven largely by substance misuse, but there is also evidence of overlap with other problems such as adversity in childhood, and poor living conditions.

Collectively, diverse risk factors highlight the multifaceted nature of aggression in SSDs. But, very few studies have attempted to separate the specific effect of environmental risk factors from pervasive factors, which is what this paper aims to tackle.

Availability: Published by Psychiatry Research.

Authors: Robert McCarron, DO, et al

Abstract: The need for integrative medicine arises from a growing recognition of the benefits for a holistic approach to health care, as well as a burgeoning desire by the public to take charge of their health and well-being by adopting new practices.

In a timely run-up to ACLP’s annual meeting on Promoting Whole Health through Innovative and Integrative Approaches to Consultation-Liaison Psychiatry, the authors give reasons why integrative medicine is integral to the fields of psychiatry and general medicine:

Emphasis on prevention and early-stage intervention—Integrative medicine stresses the importance of evidence-informed lifestyle and preventive measures to reduce the risk of developing or worsening existing chronic diseases. This proactive approach to health and wellness puts less emphasis on treating an advanced disease and can be routinely used by psychiatrists, while leading to better long-term outcomes.

Whole-person care—Integrative medicine emphasizes treating the whole person—mind, body, and spirit—rather than just focusing on the disease or symptoms. This approach acknowledges the complex and often unknown interactions between different aspects of a person’s health.

Personalized medicine—Each individual is unique and therefore requires a personalized treatment plan. What works for one person may not work for another, even if both have the same condition. We see this frequently when using traditional treatments for depressive, anxiety, psychotic, and other common psychiatric disorders.

Patient-directed motivation and empowerment—Patients are encouraged to take an active role in their health and related decisions. By leading the approach to their care and utilizing a team-based approach with the medical team, patients are more likely to benefit from treatment plans and make lifestyle changes that support their well-being. Put another way, if the treatment plan is mainly generated from a patient and not a physician, there is a higher chance for sustained motivation to change and improve health.

Addressing root or underlying causes—Rather than just treating symptoms, integrative medicine seeks to identify and address the root causes of health issues. This can lead to more effective and long-lasting solutions.

Filling gaps in conventional medicine—Some conditions, such as chronic pain, depression, anxiety, bipolar disorder, insomnia, or fatigue, might not be adequately addressed or fully explained by conventional medicine alone. Integrative medicine offers additional options and support for managing these often-complex conditions.

Supporting the patient—For individuals undergoing treatment for serious conditions such as schizophrenia, bipolar disorder, posttraumatic stress disorder, or increased risk for self-harm or suicide, integrative therapies can provide supportive care to help manage side-effects, improve quality of life, and enhance overall well-being.

Importance: Together with practical pointers, this article from an APA publication provides useful background reading for established clinicians looking to incorporate integrative medicine into their practice.

As the authors say: “Understanding how to incorporate evidence-informed integrative medicine approaches to care, while we continue our career-long search for the root cause of psychiatric disorders, will help our patients recover quicker and more fully.

“Discussing the importance of wellness—in place of disease—with our patients can be therapeutic in itself. For example, discussing treatments to advance ‘happiness’ with a patient who is struggling with depression may be forward-thinking and more goal-directed. Redirecting thoughts and real-time focus with mindfulness techniques can be an added feature to traditional psychotherapy. Psychiatrists can encourage lifestyle changes to improve health and promote wellness among their patients.”

Availability: Published by Psychiatric News.

Authors: Michael Bostwick, MD, FACLP, et al

Abstract: As more American states legalize medical aid in dying (MAID), C-L psychiatrists will increasingly be asked to assist medical and surgical colleagues in differentiating this end-of-life practice from suicide.

Where suicide is traditionally understood as an act clouded by depression, desperation, or both, MAID represents a terminally medically ill patient's effort to take control of their dying process when death is imminent, likely to occur within six months, and inevitable.

Rendering opinions on patient suicidality in the setting of a complex co-occurring medical illness is a C-L psychiatrist's bread and butter, say the authors. This paper seeks to elucidate four points that distinguish MAID from suicide:

• Hastening death when the end of natural life is approaching is not synonymous with suicide in the vernacular American usage of the term.
• Unlike suicide, MAID is a highly collaborative process in which dying, mentally capable adults involve their doctors and loved ones in legally recognized decisions to hasten death.
• The clinical presentation of patients requesting MAID differs from that of individuals whose suicidality is driven by psychopathology.
• Certain behavioral traits differentiate such MAID patients from suicidal patients.

Understanding and applying these distinctions in the C-L Psychiatry arena will help remove the stigma of suicide from end-of-life care deliberations where it does not belong, while ensuring appropriate end-of-life care for dying individuals for whom MAID is the culmination of a carefully considered process of self-determination rather than suicide, say the authors.

“Patients already have the well-established legal right to refuse or forego treatment, and to stop eating and drinking—all choices that certainly hasten death but are not considered suicide,” say the authors. “Why is MAID fundamentally different? We believe the psychiatric community has a profound duty to move beyond theoretical, linguistic, and morality-based debates about what constitutes suicide.”

Importance: As the authors say: words matter. C-L psychiatrists are well-placed to change words used by clinicians around suicide.

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

Authors: Shanshan Wang, PhD, et al.

Abstract: An online survey in March 2022 of 801 Ukrainian adults, conducted one month after Russia's February 2022 invasion, found that 54.1 % of participants had anxiety and 46.8 % had depression.

Approximately six months after Russia's invasion, an online survey of 2,004 adult Ukrainians with children under age 18 years found that, based on self-report, 62.1% of participants thought their depressive symptoms had increased since the war's onset, 71.9% thought their anxiety symptoms had increased, and 46.8% reported that feelings of loneliness had increased.

One year after the invasion, 14.4 % of adults living in Ukraine had probable PTSD, and 8.9 % had CPTSD. 44.2 % of Ukrainian adults had depressive symptoms, and 23.1 % anxiety symptoms. Quality of life was negatively associated with PTSD/CPTSD, depression, and anxiety.  Maladaptive coping positively correlated with PTSD/CPTSD, depression, and anxiety. Quality of life was positively associated with using adaptive coping strategies.

“Our aims were to provide new information on the prevalence of mental health disorders in Ukrainian residents more than one year after Russia's full-scale invasion,” say the authors, “to provide the first description of quality of life of Ukrainians during the war, and to identify factors associated with mental health symptoms and quality of life in the Ukrainian population.”

Participants were recruited through emails, app notifications, or text messages from April 5, 2023, to May 15, 2023, 14–15 months after the invasion, by TGM Research which maintains a nationally representative survey panel in Ukraine. A total of 4,641 individuals responded to the survey.

“Our study is the first, to our knowledge, to report the prevalence of mental health disorders in adults living in Ukraine over a year into the Russo-Ukrainian war, and the first to describe quality of life in the population during the war,” say the authors...”Our study is the first to provide evidence regarding the impact of cumulative exposure to armed conflicts on mental health symptoms and quality of life among Ukrainians.”

Importance: This highly detailed statistical analysis is a sobering reminder of the impact at speed of an invasion and war on an extensive population—and of the potential trauma among refugees from war zones.

Availability: Published by Psychiatry Research