A&E Abstracts and Extracts

Authors: Lizanne Schweren, PhD, et al.

Abstract: What are outcomes in young people requesting medical assistance in dying based on psychiatric suffering (MAiD-PS)?

In this cohort study of applications for MAiD-PS by 353 Dutch people younger than 24 years between 2012 and 2021, 47% of applications were retracted and 45% were rejected. For 3% of applications, patients died by MAID, and for 4%, the patient died by suicide during the application process.

“The findings suggest that there is an urgent need for more knowledge about persistent death wishes and effective suicide prevention strategies for this group,” say the authors.

So they set out to assess the proportion of requests for, and deaths by, MAiD-PS among young patients, outcomes of their application and assessment procedures, and characteristics of those patients who died by either MAiD or suicide.

The study was at the Expertisecentrum Euthanasie, a specialized health care facility providing MAiD consultation and care. All patients who died by suicide or MAiD had multiple psychiatric diagnoses (most frequently major depression, autism spectrum disorder, personality disorders, eating disorder, and/or trauma-related disorder) and extensive treatment histories.

Twenty-eight of these patients (96.5%) had a history of suicidality that included multiple suicide attempts before the MAiD application. Among 17 patients who died by suicide, 13 of 14 (92.9%) had a history of crisis-related hospital admission, and nine of 12 patients who died by MAiD (75%) had a history of self-harm.

Dutch law provides a comprehensive framework to allow, under specific circumstances, MAID for patients with unbearable and irremediable suffering, including patients with psychiatric disorders. Dutch law exempts physicians from prosecution who terminate the life of a patient or aid a patient in terminating their own life if the physician is convinced that the patient’s request is voluntary and well-considered, and the patient’s suffering is unbearable, with no prospect of improvement, and they have informed the patient about their situation and prognosis.

They must come to the conclusion, together with the patient, that there is no reasonable alternative in the patient’s situation; have consulted at least one other independent physician, who must see the patient and give a written opinion on whether the aforementioned criteria have been fulfilled; and exercise due medical care and attention in terminating the patient’s life or assisting in the patient’s suicide.

The number of people dying by MAID-PS in the Netherlands increased from 41 in 2014 (0.2 per 100 000 inhabitants) to 138 in 2023 (0.8 per 100 000 inhabitants). At the same time, the proportion of deaths by MAID-PS among all deaths by MAID remained low (0.8% in 2014; 1.5% in 2023). Yearly suicide rates in the Netherlands have, since 2014, been relatively stable, with an average of 10.8 per 100 000 inhabitants. Patients requesting MAID-PS are often female, have multiple psychiatric diagnoses, and have a long history of psychiatric treatment.

Dutch law grants people aged 16 years or older the right to independent medical decision-making and children aged 12 to 16 the right to shared decision-making alongside their parents or guardians.

Irremediability of mental illness is controversial, especially when a young and physically healthy patient might be expected to live for many years, during which new treatments might be discovered. In addition, ongoing neurobiological development during adolescence may affect competency of decision-making.

Importance: Little is known about this population. As the authors say: “Medical professionals, and societies worldwide, struggle with ethical questions regarding MAiD-PS, especially in young persons. There is an urgent need for more knowledge about this group.”

Availability: Published by JAMA Psychiatry.

See also: JAMA Psychiatry editorial.

Authors: Heather Brom, PhD, RN, et al.

Abstract: Transitions are challenging for patients with serious mental illness (SMI) and chronic medical conditions. Few programs address their unique needs. Those that do focus on coaching, medication management, and counseling. Such programs improve quality of life, and medication adherence, but have mixed readmission results, say the authors. Programs vary, but few address health-related social needs. This population tends to be Medicaid-insured and disproportionately experiences health-related social needs.

The aim of this scoping review was to identify the elements and outcomes of hospital-to-home transitional care programs for people diagnosed with SMI. Three databases were searched; 10 articles describing eight transitional care programs, published from 2013 to 2024, were examined. Five programs focused on patients discharged from a psychiatric admission.

Program lengths ranged from one month to 90 days post-hospitalization. They evaluated quality of life, psychiatric symptoms, medication adherence, readmissions, and emergency department utilization. Overall, there were positive improvements for participants: better quality of life, an increased share in decision-making, and connections to primary and specialty care providers. But “notably, few programs appeared to directly address the unmet social needs of participants.”

Importance: Annually, more than 14 million (one in 20) adults in the US  experience SMI. Nearly 40% have four or more chronic conditions, such as diabetes, cardiovascular disease, and chronic pain leading to a worse quality of life, difficulties with self-management, and higher rates of rehospitalization for medical and psychiatric reasons.

While known rates of SMI are slightly higher among non-Hispanic White individuals; Black, Hispanic, and Asian patients with mental illness are less likely to access mental health services and Black patients with SMI experience higher hospitalization rates and lower receipt of medications.

Additionally, patients with SMI are more likely to have concurrent substance use disorder, experience homelessness, and be insured by Medicaid. Commonly cited barriers to accessing care for patients with SMI include affordability, not knowing where to go for services, perceptions they can handle it on their own, and not having time to get treatment.

“Patients diagnosed with SMI experience more frequent rehospitalizations and poorer outcomes following hospitalization, which could be due in part to poor care transitions,” say the authors.

“The period of transition from hospital to home can be especially sensitive. Medications may change, hospitalization may exacerbate mental and physical health conditions, and it may be difficult reconnecting to care in the community, especially for mental health support. Additionally, patients with SMI have a higher burden of social needs that often go unaddressed.”

Many hospital-to-home transitional care programs focus on older adults, or on specific medical diagnoses, such as heart failure, say the authors, while others are beginning to focus more on the social determinants of health.

The Transitional Care Model focuses on transitioning older adults. It demonstrated reductions in readmissions and costs in randomized trials, but requires additional providers, such as advanced practice nurses. Community health workers have helped reduce readmissions for patients with a high burden of social determinants, yet they do not immediately address the complex clinical needs of patients.

The Camden Coalition Core Model, which provides support to ‘high-cost/high-needs patients,’ did not reduce readmissions in its randomized trial for high-cost patients. Similarly, the C-TraIn model for economically disadvantaged adults did not reduce 30-day readmissions or emergency department visits.

“While there are promising aspects of each of these models,” say the authors, “none focus specifically on the needs of patients with SMI and co-occurring medical conditions as they transition from hospital to home. We sought to fill this gap.”

Availability: Published by General Hospital Psychiatry.

Authors: Greg Robbins-Welty, MD, MS, et al.

Abstract: Palliative care is the standard of care for patients with serious medical illnesses, or those conditions associated with high risk of mortality and negative impact on quality of life. Electroconvulsive therapy (ECT) is the gold standard treatment for certain psychiatric conditions, which may co-occur with serious medical illnesses. However, the use of palliative ECT (PECT) in this context is understudied.

The authors studied the indications, outcomes, and regimens of PECT. They included patients who had an ECT consultation, in addition to either a palliative care consultation or a do-not-attempt-resuscitation code status between 2018 and 2023.

Thirty-one patients met inclusion criteria and 21 received ECT. The cohort was predominantly female (70%) with a mean age of 67.6. Catatonia and treatment-resistant depressive disorder were the most common indications for ECT.

At the time of ECT consultation, 16 patients had a serious medical illness, including cancer or end-organ disease. Fourteen had major neurocognitive disorder. Surrogate decision-makers consented for ECT in 64.5% of cases.

All 21 patients who received ECT experienced psychiatric symptom improvement. ECT was associated with reduced mortality risk in five cases. Five patients initially misdiagnosed with MNCD experienced recovery in cognitive function after ECT and the diagnosis was revised to depression-related cognitive dysfunction. Eight patients retained a comorbid MNCD diagnosis but experienced a mean Montreal Cognitive Assessment improvement of five points with ECT.

ECT has been shown to be an effective and safe treatment for catatonia and severe bipolar, depressive and psychotic disorders, even in the setting of serious systemic comorbidity, say the authors. ECT is commonly employed in treatment-refractory conditions, and research has consistently demonstrated that it provides psychiatric symptom reduction more effectively and more rapidly than with medications alone. While the mechanism remains unclear, it is hypothesized that ECT’s therapeutic effect stems from neuroplastic changes and neurogenesis.

“Given the efficacy and efficiency of ECT as a treatment modality, as well as the consensus that treating psychiatric disorders aligns with palliative care philosophy, clinicians may consider the use of PECT,” say the authors.

Yet, there are several barriers to providing PECT to SMI patients, including stigma associated with ECT; concerns about procedural risks in medically fragile patients; logistical challenges related to the frequency of treatments; and lack of awareness or experience among medical clinicians of the use of ECT in this population.

“Furthermore, many hospitals cannot provide ECT, especially to patients medically hospitalized and requiring more intensive care and monitoring during and after the procedure.”

Importance: This work identifies cases when ECT was beneficial or deemed unsuitable. Patients with serious medical illnesses who also had an indication for ECT experienced improved quality of life with ECT. Misdiagnoses were effectively addressed through ECT. The findings underscore the importance of cross-specialty collaboration between C-L Psychiatry and palliative care.

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

Authors: Sarayna McGuire, MD, MS, et al. 

Abstract: Acts of violence occurring in the health care setting that involve weapons result in significant morbidity and mortality. New passive weapons screening technology (PWST) offers a potential protective measure. The authors’ objective was to quantify the volume of weapons detected and deterred from their emergency department over 12 months and determine whether it led to weapon-carrier hostility towards frontline staff.

The emergency department of a large, academic, Level 1 trauma center in a Midwest city with an average annual volume of 80,000 patients was the setting for their research.

Before PWST was implemented, average monthly weapons detection was ≤1. Post PWST, between 11/1/22 and 10/31/23, 1,741 weapons were detected, including knives, firearms, and other/improvised weapons. “We found a concerning rate of attempts to bring weapons into our emergency department,” say the authors.

Responding to a survey question about interactions where a weapon was detected, most security staff reported the weapon-carrier was not upset with the prevention of weapon(s) from entering the hospital.

Importance: Workplace violence is common in health care and accounts for high rates of non-fatal injury. Fatal injuries are rare. Health care-based shootings occur on average 17 times per year across the US, a rate that has been increasing. Most health care-based shootings are targeted at specific individuals or involve a ‘fit of rage’ where the perpetrator exacts violence on targets of convenience.

Studies have primarily assessed weapons detected by traditional metal detectors. However, this technology has several drawbacks, limiting its use in the health care setting. PWST offers an alternative and is increasingly used: it detects weapons by shape and emphasizes speed and accuracy compared to traditional technology.

Prior literature had not assessed PWST performance and impact in the health care setting. Yet, even then, this research does not include weapons which may be entering the emergency department undetected via patients transported by emergency medical services, or via people entering through subsidiary hospital entrances.

Availability: Published by The American Journal of Emergency Medicine.

Authors: Jia-Li Liu, MD, et al.

Abstract: Internet-delivered transdiagnostic psychological interventions are promising approaches for the treatment of anxiety and depression. This study is an analysis of Internet-based transdiagnostic psychological interventions, such as universal transdiagnostic interventions and tailored transdiagnostic interventions, to assess their efficacy in alleviating depression and anxiety.

It provides practice recommendations for implementing Internet-based transdiagnostic interventions in mental health care and highlights the need for further research to explore the mechanisms of change and integration into clinical practice.

The authors identified 42 trials with a total of 4,982 participants. Compared with the control group, the Internet-delivered interventions reduced both anxiety and depression.

Transdiagnostic psychological interventions fall into two broad categories: universal and tailored interventions, such as the Unified Protocol approach for transdiagnostic treatment of emotional disorders, provide a set of universal interventions for target populations with broad applicability.

Tailored interventions can be adjusted to participants’ unique clinical symptoms, personal preferences, and characteristics such as motivation or education level. For example, ‘I Care Prevent’ for college students allows participants to choose modules and sequences based on their needs.

This analysis evaluated the effectiveness of Internet-delivered interventions on anxiety disorders, depression, and quality of life. It showed that universal intervention is more effective than tailored intervention. “It is encouraging that such intervention can lead to significant improvements and diagnostic recovery with minimal clinician guidance,” say the authors.

Importance: According to the World Health Organization, as of 2023, 3.8% of the global population currently experience depression, and 4% experience an anxiety disorder.

Although anxiety disorders and depression are often distinguished clinically, say the authors, there is high comorbidity between anxiety disorders (particularly generalized anxiety disorder or panic disorder) and depression due to the likelihood of similar psychological and biological mechanisms between them.

For patients with a single disease, suffering from anxiety and depression at the same time leads to more serious physical and mental disorders, relatively higher suicidal intention, and greater social and economic burden. “This highlights the importance of studying comorbid anxiety and depression to develop effective interventions that address both conditions simultaneously.”

Availability: Published by Psychiatry Research.