A&E Abstracts and Extracts

Authors: Joseph Flaxer, MD, MPH, et al.

Abstract: Medically-unexplained behaviors and symptoms (MUBS) are challenging for patients, families, and clinicians alike. They demand consideration of more than biological determinants, warranting biopsychosocial assessment as well as psychodynamic formulation.

Here the authors present a case of an 80-year-old woman with a history of multiple oropharyngeal traumas who presented to the emergency department for a recently developed acute anorexia associated with fear of choking (phagophobia). She presented with complex psychological dimensions, such as survivor guilt related to losing her spouse to gastroesophageal cancer.

Through a psychodynamic and biopsychosocial lens, the authors discuss how her predisposing developmental history of trauma and fear responses; perpetuating gastrointestinal issues, unresolved grief, and survivor guilt; and more recent age-related neurocognitive changes inform her presentation and response to treatment.

Phagophobia or ‘fear of choking’ calls for comprehensive medical evaluations to exclude organic etiologies, including infectious, cancerous, and other conditions, say the authors. C-L psychiatrists add value in reminding primary medical teams of this imperative, minimizing stigma or oversimplified conceptualizations of ‘psychogenic’ etiology. However, once medical phenomena have been ruled out, stabilization of psychiatric comorbidities makes intuitive sense.

Importance: As the authors say, MUBS are difficult to navigate, demanding more nuanced assessments and psychologically-informed considerations. This case of phagophobia is emblematic of the problem faced by C-L psychiatrists: conventional medical approaches do not suffice, demanding an integration of biological information with psychobehavioral factors. C-L psychiatrists are uniquely equipped to synthesize medical data, anticipate psychological forces, and balance other information.

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

Authors: Zhilan Ke, School of Nursing, Hubei University of Chinese Medicine, et al.

Abstract: Immersive Virtual Reality (IVR) is being investigated and tested as a potential intervention tool for addressing the increasing prevalence of psychological issues among older adults. This review aims to assess the effectiveness of IVR devices in enhancing their psychological well-being.

Conclusions were that IVR has the potential to improve the psychological health of older adults and may be widely applicable in promoting successful aging.

The number of older adults is growing faster than any other age group and is projected to more than double, reaching over 2.1 billion, by 2050. As demographic aging accelerates, there is a growing global focus on promoting healthy aging. The likelihood of experiencing better health and successful aging in older adults is associated with higher levels of psychological well-being. However, depression and anxiety are prevalent among the older population: studies indicate that 7% of older adults suffer from major depression and 14% experience anxiety disorders.

Among the active aging interventions built upon this background, preventive exercise, treatment, and rehabilitation can be facilitated through progressively evolving technologies over the next two decades such as digital medicine, genomics, robotics, and artificial intelligence. IVR has been shown to improve psychological health in older adults, leading to better mood, reduced anxiety, and fewer depressive symptoms.

IVR utilizes head-mounted displays or similar immersive environments to create sense-enriched virtual experiences that simulate the user's physical presence in a digital space. Modern head-mounted displays feature a monitor for each eye, providing a stereoscopic image—a 360-degree panoramic view of a virtual environment that responds to the user's head movements. It creates an interactive learning environment using 3D VR simulations, offering an ‘immersive experience’ that enhances learning.

Such devices have been used in post-stroke rehabilitation, mobility and balance training, combating depression, cognitive training for neurodegenerative diseases, and preventing falls in the elderly. This capability allows users to experience nature or reminisce about scenes even when they are unable to go outdoors.

IVR helps improve mood, apathy, and cognitive functioning and is shown to be well-received among individuals with dementia or mild cognitive impairment. One study involving 30 older adults found that a six-week VR program was beneficial, user-friendly, and enjoyable, with participants expressing positive perceptions toward accepting and using it. Another study on a two-week IVR intervention revealed that the experimental group using IVR experienced less social isolation, demonstrated fewer signs of depression, and reported better overall well-being compared to those who watched TV.

“Moreover,” say the authors, “this technology has become more affordable, technically accessible, and user-friendly...However, the use of head-mounted displays may present health and safety concerns, as exposure to virtual reality environments can result in side-effects or after-effects such as eyestrain, nausea, and headaches.

Importance: Given the substantial evidence supporting virtual reality as an effective treatment for affective disorders in younger populations, the potential for IVR interventions to address mood spectrum disorders and other psychiatric conditions in older adults is equally promising. However, there is a scarcity of studies that summarize the effectiveness of IVR interventions on psychological outcomes through meta-analysis. This study aims to fill this gap by synthesizing quantitative data.

Availability: Published by General Hospital Psychiatry.

Authors: Carol Lee, PhD, et al.

Abstract: Cannabis use is increasing in the US and, on average, those consuming medical cannabis report more frequent cannabis use than those who use recreationally. This analysis focuses on the prevalence and correlates of working under the influence of cannabis (WUIC) amongst individuals with chronic pain who use cannabis medically.

Adults were recruited from medical cannabis certification clinics in Michigan. WUIC was reported by 34% of employed medical cannabis patients. Older age and having episodes of six+ drinks were significantly associated with lower odds of WUIC. History of driving under the influence of cannabis, reporting three+ hours high on cannabis per day, and using 0.5 oz+ of cannabis per week were all significantly associated with higher odds of WUIC.

“Amongst individuals who use cannabis for pain and are in the workforce, WUIC is relatively common,” say the authors. “This may be particularly concerning in jobs that are safety-sensitive. Prevention efforts for WUIC might focus on those who use cannabis several times per day and might consider how to balance the needs for pain management with workplace-related roles.”

Importance: As of 2023, 39 states including the District of Columbia had legalized use of cannabis for qualifying medical conditions. In 2022, nearly 59 million adults used cannabis in the previous year; approximately 25% had a full-time job and 28% a part-time job. Given access to cannabis for medical purposes across much of the US,  it is important to understand how cannabis consumption relates to employment behaviors and WUIC. However, a recent systematic review concluded that data on the relationship between WUIC and work safety was limited and results were inconclusive.

In one of the few existing studies of links between cannabis use and work-related outcomes, a national study of postal workers found that those who tested positive for cannabis in a pre-employment screening had 55% more industrial accidents, 85% more injuries, and 75% greater absenteeism compared to those who tested negative.

In addition, the National Safety Council released a position statement in 2019 signifying that cannabis impacts psychomotor skills and cognitive ability and that there is no level of cannabis use that is safe nor acceptable for employees who work in safety-sensitive positions that engage in high-risk and safety-related job functions. “It is imperative to close the knowledge gap in understanding the context and temporality of impairment to assess the causal relation between cannabis use and negative consequences of WUIC,” say the authors.

Availability: Published by The American Journal on Addictions.

Authors: Arian Zaboli, RN MSN, et al.

Abstract: Triage is essential in emergency departments (EDs) to prioritize patient care based on clinical urgency. Recent investigations have explored the role of large language models (LLMs) in triage, but their effectiveness compared to human triage remains uncertain. This study assessed the effectiveness of Chat-GPT 4.0 in triaging ED patients.

The authors analyzed data from 2,658 patients at the ED of Merano Hospital, Italy, which handled approximately 64,000 visits in 2023.Triage codes assigned by human triage personnel were compared with those assigned by Chat-GPT. Clinical outcomes were evaluated through Receiver Operating Characteristic (ROC) curves to determine predictive accuracy.

Analysis demonstrated that human triage outperformed Chat-GPT 4.0 in predicting all study outcomes, with statistically significant differences. For 30-day mortality, the ROC of human triage was 0.88, while for AI triage it was 0.70. A similar result was observed for life-saving interventions, where human triage had an ROC of 0.98 and Chat-GPT triage 0.87. “For specific symptoms, human triage showed superior sensitivity and specificity,” say the authors. “LLMs like Chat-GPT 4.0 have limited utility in ED triage, particularly due to their lower sensitivity for high-risk patients, which lead to under-triage. Human triage remains more reliable than Chat-GPT.”

Importance: This study demonstrates that LLMs such as Chat-GPT 4.0 do not outperform human clinicians in triage accuracy. While AI triage was effective at identifying high-risk patients, it often led to over-triage, resulting in inefficient patient stratification. Moreover, Chat GPT’s poor sensitivity in detecting severe cases among low-priority patients raises concerns about its safety in clinical practice. In contrast, human triage showed better concordance with actual patient.

Availability: Published by The American Journal of Emergency Medicine.

Authors: Patrick Ho, MD, MPH, et al.

Abstract: C-L psychiatrists are trained extensively in the clinical aspects of our work, but must work within the confines of the health care apparatus with overarching policies that dictate the affordability, accessibility, and quality of medical care, say the review authors.

It has become clear that a change in the US presidential administration will affect health care policy. Local and state level elections, however, may have an even more profound impact on health care policy.

“With many C-L psychiatrists feeling trepidation about these changes, we call for C-L psychiatrists to take part in legislative advocacy activities, especially at the local/state levels that are more accessible and perhaps more impactful,” say the authors.

“We recognize that important barriers include lack of formal education, as well as time constraints and have devised the Hawkes Tiered State and Local Advocacy Activity List as a practical compendium of legislative advocacy actions that C-L psychiatrists can participate in, stratified by the amount of time required to take part in each activity.

“We hope that this will empower C-L psychiatrists to participate in legislative advocacy activities, as the stakes are higher than ever, and we cannot afford for our perspectives to not be included in policy and legislation that can have major consequences for our patients and our practice of medicine.”

Importance: This call to action at state-level is supported with practical guidance.

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