Abstract: Postpartum depression (PPD) is a common condition affecting one in seven postpartum individuals. In 2019, the Food and Drug Administration approved brexanolone, the first medication for PPD, based on two phase 3 clinical trials sponsored by the pharmaceutical company.

Few independent studies have been published looking at clinical outcomes related to brexanolone. At Dr. Lavingia’s tertiary care obstetrical hospital, brexanolone has been administered by the C-L service since March 2020. This study investigates longitudinal outcomes of patients receiving brexanolone.

Patients receiving brexanolone are asked to complete the Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7) electronically at eight timepoints beginning just prior to infusion and ending 60 days post-infusion, as well as the Barkin Index of Maternal Functioning (BIMF) prior to infusion and at seven, 30, and 60 days post-infusion. A mixed model regression examines changes in scores over time.

Since implementation, 33 individuals have been referred for brexanolone and 16 have received the infusion. Of the 16, 100% completed the initial questionnaires prior to infusion, and nine the final questionnaires at 60 days post-infusion.

Patients who received brexanolone exhibited a clinically and statistically significant decrease in PHQ-9 scores and increase in BIMF scores, and a smaller but significant decrease in GAD-7 scores.

A significant strength of this study is its independence in a real-world clinical program, says Dr. Lavingia. (Individuals demonstrated sustained responses to brexanolone at 60 days post-infusion, while previously published studies followed patients until day 30.) Future efforts in the study will include assessment of barriers to accessing brexanolone to increase the availability of the medication among vulnerable populations.

Michael Peterson, MD, PhD, FACLP: Brexanolone has been considered a ‘breakthrough’ medication, both as an option specifically for post-partum depression, but also due to a non-monoaminergic mechanism of action. However, due to cost and need to administer via infusion, use is relatively uncommon in many practice settings. This presentation shares data from a real-world case series, with lessons learned about how we may be able to integrate this treatment option for patients in our home institutions.

Abstract: Depression and anxiety disorders affect 12-15% of individuals with cardiovascular disease. Following acute cardiac events, these disorders are associated with impaired recovery. Blended collaborative care interventions, where a care manager facilitates the treatment of both psychiatric and medical disorders within the framework of existing care, appear to be effective at improving mental health, and in some cases physical health, outcomes.

However, existing collaborative care programs have focused on individuals with stable cardiovascular disease, despite the potential benefits of initiating these interventions during hospitalization to promote recovery following acute cardiac events.

Accordingly, Dr. Celano, et al., developed Total Health, a six-month blended collaborative care program to promote mental and physical recovery following acute cardiac events. In this randomized clinical trial, they examined the efficacy of the Total Health program, compared to enhanced usual care, in 260 adults hospitalized for an acute coronary syndrome or heart failure exacerbation and found to have clinical depression, generalized anxiety disorder, and/or panic disorder.

The participants were randomized to receive the Total Health program or enhanced usual care. In the Total Health program, they received phone calls from nurse care managers, who assessed psychiatric symptoms, cardiovascular symptoms and signs (i.e., weight for individuals with heart failure, blood pressure for those with hypertension), and health behavior adherence. With input from a psychiatrist, psychologist, and cardiologist, the nurse care manager communicated treatment recommendations to the participant’s outpatient providers. Follow-up assessments were at 26 and 52 weeks post-randomization.

Statistical analysis is ongoing. “We will present the main findings of the trial, including the impact of Total Health on function, psychological, physical, and health behavior outcomes,” says Dr. Celano. “We hypothesize that the program will lead to significant increases in function, reductions in depressive and anxiety symptoms, and improvements in other outcomes.”

He adds: “Results of this trial will add significantly to collaborative care literature, which has found collaborative care to be a promising treatment option for individuals with comorbid psychiatric and medical conditions, but has received little attention in acute medical settings. If effective, the Total Health program has the potential to be implemented in clinical care to improve the recovery of patients hospitalized for acute cardiac events.”

Michael Peterson, MD, PhD, FACLP: Collaborative care has become a cornerstone of outpatient psychiatric care, delivered in ambulatory clinical settings. The ability to improve psychiatric and general medical outcomes to more patients where they already receive other types of medical care is a tremendous resource. Extending this model of care to a wider range of diagnoses and severity is a key strategy for future expansion. Dr. Celano and colleagues will be presenting their experience specifically with implementing a collaborative care model specifically for post-acute cardiac patients. This is a high need population, and this model can likely be applied to other specific post-acute medical/surgical admissions.

Abstract: There are few formal curricula aimed at teaching hospitalists how to manage agitation in the general medical setting. Certain populations, specifically patients with acquired brain injury (ABI), dementia, and intellectual and developmental disability (IDD) are at higher risk for developing agitation with medical care outside of the setting of delirium due to pervasive cognitive barriers. Internal medicine providers are often first-line clinicians to experience agitation and receive little formal training in treating it in patients with ABI, dementia, and IDD. These providers may benefit from online learning modules tailored towards teaching them agitation management, especially in patients with ABI, dementia, and IDD.

Thirty-four hospitalists (74% physicians) at Johns Hopkins—Bayview completed a needs assessment survey, the modules, and a post-assessment survey. Phase two involves launching the modules at two other Johns Hopkins sites; development and dissemination of vignette-based cases and a study guide; and assessment of changes in provider practices and clinical outcomes.

“Phase one demonstrated positive responses in terms hospitalists’ attitudes and confidence in management,” says Dr. Tobolowsky, et al. “An online training module can be helpful in improving the confidence of managing agitation among hospitalists. Improving provider knowledge, attitudes, and skills has the potential to result in better patient outcomes.”

Michael Peterson, MD, PhD, FACLP: Management of acute and recurrent agitation in the hospital setting is a common consult request. With the increased acuity of hospitalized patients, an aging population, and limited options for disposition of patients with dementia and behavioral disturbance, the number of agitation consults continues to grow. Additionally, many hospitals do not have a psychiatric consultation service. For both reasons, educating (general medical) hospitalists on agitation management can hopefully improve the confidence of hospitalists to independently manage agitation in an evidence-based and effective manner. This type of education may also allow our C-L services to triage and focus on more complex case needs.

Abstract: Transplant psychiatrists play a crucial role in the multidisciplinary assessment of transplant candidates and care of transplant recipients. The scope of the role can range from risk stratification to candidate optimization, medication management, and perioperative and post-transplant psychiatric care. The role may also necessitate recognition and management of psychodynamic elements and transference forces, not only with the patient, but also within the team.

“The wide range can lead to ambiguity and confusion about the precise nature of the role of the transplant psychiatrist within each individual transplant center,” says Dr. Deka, et al. “This project aims to address this gap by investigating the perceptions, expectations, and realities of the role of transplant psychiatrists among members of transplant teams as well as transplant psychiatrists themselves.”

Using a survey, the team is collecting data from transplant team members from US transplant centers, including surgeons, hepatologists, nephrologists, social workers, pharmacists, psychologists, and psychiatrists.

“We expect heterogeneous responses to the survey underscoring the protean yet nebulous nature of this role,” says Dr. Deka. “We also anticipate discrepancies in perceptions and expectations among different members of the transplant team. Investigation of such anticipated heterogeneity and discrepancies may allow us to better understand transference forces impacting team dynamics. This will also empower transplant programs to specify more clearly the perceptions and expectations of the role of the transplant psychiatrist.

“By identifying areas for improvement and enhancing collaboration, we can ultimately enhance the quality of care provided to transplant recipients, improve their overall transplant experience. and improve transplant team dynamics.”

VaKara Meyer Karre, MD: More than 45,000 organ transplants were performed in the US in 2023, many with the involvement of a transplant or C-L psychiatrist. Similar to the transplant process itself, the role of a transplant psychiatrist within a transplant team is complex and fraught with ambiguity. Using a survey methodology, the authors aim to investigate the role of a transplant psychiatrist by exploring perceptions, expectations, and realities of the role as noted by various members of the transplant team, including the transplant psychiatrist. Outcome goals include empowering transplant programs to define the role of the transplant psychiatrist, identify areas for improvement/enhance collaboration, and ultimately improve the quality of care provided to transplant recipients.

Abstract:  Antipsychotics have an important role in the treatment of acute agitation, but the use of intravenous (IV) antipsychotics is relatively specific to consultation-liaison and emergency settings. “There is limited literature about the safety and efficacy of IV antipsychotics, so their use is inconsistent across settings and institutions,” says Dr. Dragonetti. This retrospective study reports safety outcomes with use of IV olanzapine in medical, surgical, and intensive care settings, and contextualizes findings within current literature about IV antipsychotics.

The study reviews patients aged 18+ admitted to an urban general hospital who received at least one dose of IV olanzapine. Vital signs in the four hours following each dose were reviewed for hypotension, bradycardia, bradypnea, and oxygen desaturation. The serious adverse outcomes screened for were intubation and death. Confounding and contextual factors reviewed include concomitant medications and use of physical restraints.

Data from this study—approved by the Institutional Review Board—adds to literature about safety of IV antipsychotics and may help clarify if there is a role for use of IV second-generation antipsychotics (SGAs) for patients on medical-surgical and intensive care units.

Currently, no antipsychotics are Food and Drug Administration-approved for intravenous use. “Haloperidol is generally observed to be the most commonly used IV antipsychotic due to widespread familiarity,” says Dr. Dragonetti. “However, SGAs are generally found to have better safety profiles compared to first-generation agents, so it is worth expanding our understanding of the safety and efficacy of IV SGAs to better clarify their role in the treatment of general hospital patients.

“Many previous studies on IV olanzapine have taken place in emergency department settings in which the patient population may be distinct from hospital inpatients. Considering the limitations of most studies to date, further prospective and comparative studies will help clarify the role of IV SGAs.”

VaKara Meyer Karre, MD: Antipsychotics are frequently used in the management of acute agitation, particularly in hospital and emergency settings, with the majority of these medications administered via oral or intramuscular routes. There are times, however, when intravenous medication (IV) is preferred or even necessary. Although there are no antipsychotics FDA-approved for intravenous use, Haloperidol is the most commonly used IV antipsychotic. Given the overall safer profile of second-generation antipsychotics (SGAs) to first-generation antipsychotics, the authors note it worthwhile to expand our understanding of the safety and efficacy of IV SGAs. To this end, they performed a retrospective chart review of patients administered IV Olanzapine over a nine-year period and then complied/presented the findings with the caveat that additional studies will be helpful to further clarify the role of IV SGAs.