Dr. Peterson: “End-of-life discussions remain challenging for physicians, even C-L psychiatrists. However, addressing these needs has a clear impact on quality of life for patients. C-L psychiatrists draw on their therapy skills in addition to the rest of our ‘toolbox’ in managing anxiety—of both other providers and patients—for effective communication. The authors present their work on how psychiatrists can integrate this work on C-L services.”

Tears Without Fears: Psychopharmacologic Considerations When Treating Pseudobulbar Affect

Lead presenter: Resident physician Jake Cross, MD.

In 2010, the dextromethorphan (which antagonizes NMDA receptors and agonizes sigma-1 receptors) and quinidine (which inhibits CYP2D6 to increase levels of dextromethorphan) combination drug (DQC) became the first approved treatment of pseudobulbar affect (PBA), characterized by episodes of uncontrollable changes in affect such as laughing or crying out of proportion to the situation. The authors describe a case of PBA and demonstrate the importance of anticipating drug interactions, notably CYP2D6 inhibition.

The patient is a 31-year-old female with a history of vertebral artery dissection and basilar artery occlusion leading to a cerebrovascular accident. She was also diagnosed with Major Depressive Disorder prior to the stroke but had not responded to multiple antidepressant medications while receiving treatment through the resident clinic.

Upon transition to a new resident, the clinical signs of her emotional incontinence were identified as more consistent with PBA and she was started on DQC. To compensate for the CYP2D6 inhibition of DQC, the doses of her concomitant 2D6-metabolized medications (amphetamine/dextroamphetamine and venlafaxine) were halved.

She reported significant improvement in crying spells and resolution of laughing episodes. However, lowering her amphetamine/dextroamphetamine worsened daytime somnolence, fatigue, and inattention. Both preceding psychotropics were increased to pre-DQC clinical effect. Ultimately, she required higher than originally expected doses of venlafaxine and amphetamine/dextroamphetamine.

One unique opportunity in the resident clinic is the regular transitions of care that facilitate scrutiny of prior diagnoses and avoidance of diagnostic overshadowing. This patient had not responded to previous treatments targeting a diagnosis that preceded her stroke, but did respond to a medication that would not have been utilized if an alternative diagnosis were not considered.

Her life stage is important as she was raising a young child, making the dysfunction secondary to her emotional incontinence even more distressing. “Adequate treatment of PBA is essential to preserve psychosocial functioning, as this diagnosis is associated with higher rates of anxiety, depression, and poorer social functioning,” say the authors. “Younger people with PBA, such as this patient, tend to report higher PBA severity and more apathy than their older counterparts.”

Recent developments in psychopharmacology leverage CYP2D6 metabolism, but a lack of specific practice guidelines, makes dose adjustments of co-prescribed CYP2D6-metabolized medications challenging. Here, the authors present an approach that prioritizes safety in adjusting other CYP2D6 substrates and discuss additional considerations for the prescribing clinician.

Machine Learning Algorithms as a New Screening Approach for Inpatient Violence and Psychosocial Intervention

Lead presenter: Jacqueline Chipkin, MD.

Inpatient aggression and violence are broad outcome measures stemming from many psychosomatic etiologies. The implementation of emergency behavioral codes to manage these events has become standard practice. “While acute de-escalation is critical, these protocols emphasize a one-size-fits-all, reactive model of containment rather than a proactive model of prevention and treatment of modifiable factors,” say the authors. “As a result, numerous adverse clinical, workplace safety, and financial outcomes ensue. However, little is known about the best way to screen patients at risk for violence in non-psychiatric units.”

In addition to machine learning from discrete EHR data, natural language processing (NLP) has been shown to predict medical readmission risk by analyzing EHR text. The importance of narrative data containing psychosocial variables such as poor social support, housing instability, depression, and substance use is uniquely suited for NLP. Therefore, the authors hypothesize that NLP has a role in screening for patients with psychosomatic complexity and propensity for violent behavior.

“We will train machine learning algorithms (MLA) to identify high-risk patients,” say the authors.

Many trainees do not receive clinical exposure to Proactive C-L Psychiatry during residency. This project aimed to create a resident elective experience in Proactive C-L Psychiatry in a hospital without a previously established proactive service.

Utilization data was gathered to identify services that frequently request psychiatric consultation. Educational objectives were identified, and the structure of a proactive screening process was developed in close consultation with the leadership of two surgical services. Two residents piloted the proactive model two days per week over a six-week block. Additionally, Psychiatry residents were administered a voluntary, anonymous survey which included brief educational material about Proactive C-L Psychiatry to assess knowledge/interest about this model. Consultee satisfaction data was being collected through summer 2023.

The authors’ review of utilization data identified limb salvage and transplant teams as two of the most common services to request psychiatric consultation, accounting for 43% of consultations from all surgical teams. These services were highly receptive to host Psychiatry residents for a proactive elective, and qualitative data collected regarding consultees’ experience was very positive.

“Proactive C-L Psychiatry has the potential to facilitate novel and attractive learning opportunities and increase resident exposure to, and interest in, C-L Psychiatry,” say the authors.

“These data suggest that it is feasible to implement an elective educational experience in Proactive C-L Psychiatry for trainees, even in settings that do not previously have established proactive services. The use of psychiatric consultation utilization data can help guide effective partnerships for similar future electives. Fostering these types of elective opportunities has the potential to increase resident interest in C-L Psychiatry and further explore the feasibility of proactive C-L Psychiatry on surgical services.”

Perinatal depression (PeriPD) is a common and disabling disorder with extensive societal costs. PeriPD occurs at even higher rates in minority and socioeconomically disadvantaged populations who are often underrepresented in studies of PeriPD’s mechanisms.

Emotional processing of infant faces is disrupted in postpartum depression. The authors hypothesize that disruption of this key process is a quantifiable element of postpartum depression.

“We explore this behavioral phenotype and underlying neural circuitry on an individual basis within the Fair Start birth cohort, which recruits from a largely minority and predominantly Spanish-speaking population,” say the authors. “We are investigating how variability within emotion regulation behavior and related neural activity are linked to individual variation in depression symptoms. In this study, postpartum mothers complete an emotion regulation neuroimaging task so we can look at their brains and behavior simultaneously. This work represents the first step in developing a methodology for individual characterization of postpartum depression.”

Dr. Peterson: “Postpartum depression is a psychiatric emergency with significant impact on both the infant and birth parent. C-L psychiatrists are leaders in identifying and treating this condition in both hospital and ambulatory settings. Dr. Drysdale and colleagues present early findings from their study in a predominantly minority cohort. This study is intriguing as it draws in multiple domains: neurobiology, biological markers/phenotypes, clinical outcomes, and social determinants of health.”