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Selection from the latest research impacting C-L Psychiatry
Validation of Cerebral State Monitor Frequency Power Ratios for Detection of Delirium
Authors: Robert DeBurlo, MD, et al.
Abstract: Delirium among hospitalized patients often goes undetected and is associated with increased length of stay and mortality, say the authors. Cerebral state monitors (CSM) collect limited lead electroencephalography (EEG) data and have shown promise in delirium detection.
This study—performed at the University of New Mexico (UNM) Hospitals—assessed the discriminative power of raw EEG data obtained from a Masimo ‘Root Platform’ CSM compared to the traditional reference standard clinical evaluation by a C-L psychiatrist and the 3D-CAM.
Hospitalized patients >18 years, evaluated by the C-L Psychiatry service, were screened for inclusion with 3D-CAM, followed by placement of four frontotemporal CSM leads and five minutes of EEG data with eyes closed. Presence or absence of a delirium diagnosis on psychiatric evaluation using DSM 5 criteria on the day of data collection was recorded.
Seventy-five participants (52 non-delirious, 23 delirious) were enrolled and underwent 3D-CAM and EEG assessment. EEG data from all four leads was lacking in 14 non-delirious and three delirious patients.
CSM differed significantly between delirious and non-delirious patients but did not outperform 3D-CAM as a predictive test of delirium.
Importance: Diagnosis of delirium is associated with increased mortality, increased length of hospital stay, and increased cost of medical care. It is estimated that it affects 25 to 35% of hospitalized patients, yet commonly goes undetected.
Evaluations for delirium are a frequent request to inpatient C-L Psychiatry services. However, access to specialists is often limited after hours, in remote areas, and at subacute facilities. To improve the early detection and treatment of delirium, clinical screening instruments have been developed and validated, each with associated advantages and limitations.
Availability: Pre-publication in the Journal of the Academy of Consultation-Liaison Psychiatry (JACLP).
Developing a Measure for the Accuracy of Symptom Perception: The Congruence Between Self-Reported Dyspnea and Physiological Parameters in the Dutch Lifelines Cohort Study
Authors: Aranka Ballering, PhD, et al.
Abstract: The researchers aimed to assess whether a symptom perception accuracy measure can be derived from routinely collected general population cohort data.
They combined information on self-reported dyspnea and physiological parameters from the Lifelines Cohort Study to obtain a symptom perception accuracy measure. Using principal component analysis of available psychosocial variables known to correlate with symptom perception, they derived three compound scores reflecting negative affect, fear of illness, and worries of contracting disease. They used multi-nominal regression analyses to calculate the probability of self-reported dyspnea being correctly classified based on FEV1%pred and body weight. They showed that a symptom perception accuracy measure based on congruence between physiological parameters and self-reported dyspnea can be developed.
“People differ in their experience of symptoms in the presence of pathological processes,” say the authors. “In other words, often a discrepancy exists between objective bodily assessments of dysfunction or pathology and the self-reported symptoms that people experience due to these. This discrepancy has been found across multiple medical domains, such as orthopedics, diabetology, and pulmonology.
“It is pivotal to obtain insights into factors that determine people’s symptom experience, especially since one’s quality of life, but also treatment decisions, depend on the severity of the symptoms reported by the patient.”
The lack of easy-to-use measures for the accuracy of somatic symptom perception hinders the possibility of conducting longitudinal studies on factors influencing symptom perception processes, say the authors. The inclusion of a measure for the accuracy of somatic symptom perception in cohort studies would allow for studying elements of the predictive processing theory throughout the life course, the experiences that shape symptom perception, and their interaction with genetic factors contributing to symptom perception.
Importance: This study shows that the usability of a measure for the accuracy of symptom perception, based on the congruence between physiological parameters and self-reported respiratory symptoms, remains limited. Methods to assess individualized symptom perception need to be developed for use within large cohort studies.
Availability: Published by Biopsychosocial Science and Medicine.
Treating Depression with Repetitive Transcranial Magnetic Stimulation: A Clinician's Guide
Authors: Leo Chen, MBBS, M.Psych, PhD, FRANZCP, et al.
Abstract: Transcranial magnetic stimulation (TMS) applies electromagnetic pulses to stimulate cortical neurons. The antidepressant effect of the repetitive application of TMS (rTMS) was first shown nearly three decades ago.
The therapeutic potential of TMS has been extensively investigated, mostly in treatment-resistant depression (TRD). Studies have extensively evaluated stimulation parameters, treatment schedules, methods to localize the stimulation target, and different magnetic coil designs engineered for desired stimulation breadth and depth. Proliferation of rTMS translational and clinical research has resulted in the field’s advancement.
This clinician-oriented review contains an overview of fundamental TMS principles, physiological effects, and studies of rTMS in TRD. A synthesis of the key clinical considerations given to patient assessment and safety, treatment setup, and the minimization and management of adverse effects is provided.
Importance: Several stimulation protocols and coils/devices have received US Food and Drug Administration clearance for application in TRD and other neuropsychiatric disorders, such as obsessive-compulsive disorder. Some stimulation protocols, while not FDA-cleared, have substantial clinical trial-derived evidence to support their safety and antidepressant efficacy.
Availability: Pre-publication in The American Journal of Psychiatry.
Clinical Utility and Performance of the Traditional Chinese Version of the 4-As Test for Delirium due to Traumatic Brain Injury
Authors: Yun-Hsuan Lai, MSN, et al.
Abstract: Delirium is a common symptom following a traumatic brain injury that is often overlooked by health care professionals, say the authors. Early detection of posttraumatic delirium is crucial to improving patient outcomes and quality of life. The 4 As Test (alertness, attention, abbreviated mental test-4, and acute mental changes) is a brief and rapid tool for delirium assessment.
The authors set out to assess its reliability and validity, and explore the clinical effects of delirium in patients with a traumatic brain injury.
Conducted at the neurosurgery wards of two Taiwanese hospitals, the study engaged patients diagnosed with a traumatic brain injury, with a Glasgow Coma Scale score between 13 and 15.
One hundred patients, average age 67, were enrolled, of whom 10% were diagnosed with delirium, based on DSM 5 criteria. Patients with delirium tended to have a longer hospital stay than those without delirium (13 versus seven days). Patients diagnosed with delirium using the Short Confusion Assessment Method had a significantly higher score on the TC-4AT than those not diagnosed with delirium (P < 0.001).
Importance: The TC-4AT is shown to be a tool for delirium assessment that aids early detection and informed decision-making in preventive care.
Availability: Pre-publication in the Journal of the Academy of Consultation-Liaison Psychiatry (JACLP).
Brief Report: Effectiveness of Two Financial Incentives on Patient Follow-up After Brief Substance Use Disorder Inpatient Treatment
Authors: Mia Haidamus, BA, et al.
Abstract: Clinical follow-up data after substance use disorder (SUD) treatment provides important information about treatment effectiveness, yet compliance is a challenge. The authors compared financial incentives for obtaining follow-up data from adults receiving inpatient SUD treatment.
Participants were randomized to receive a guaranteed incentive, raffle-based incentive, or no incentive for completing a one-month follow-up assessment. Logistic regression tested the effect of incentives on follow-up completion. Those in the raffle category had >2 times higher odds of completing a follow-up assessment compared to those in the no-incentive or guaranteed-incentive categories.
Importance: Raffle-based incentives, say the authors, may improve follow-up after treatment and help clinicians evaluate SUD treatment outcomes.
Availability: Published by The American Journal on Addictions.
