Journal of the Academy of Consultation-Liaison Psychiatry最新文献

Background: Consultation-liaison psychiatry (CLP) services vary significantly across and within countries. In Flanders (Belgium), no data exist regarding the nature of CLP services in general hospitals.

Objective: This study aims to explore the CLP services in Flanders, using an online survey.

Methods: Head of the psychiatric department or head of medical services in each hospital were contacted for participation. An ad hoc survey investigated information about the CLP services.

Results: In total, 29 CLP psychiatrists of 52 eligible hospitals completed the questionnaire. All hospitals provided CLP services by senior psychiatrists (100.0%), assisted by a psychiatrist-in-training in 14 hospitals (48.3%). The time spent on CLP services was 0.5 full-time equivalent or less for the majority of senior psychiatrists (85.7%) and psychiatrists-in-training (71.4%). Seventeen hospitals (58.6%) had a multidisciplinary CLP team. In most hospitals (100.0% and 96.6%, respectively), the time to initiation of consultation was less than 24 h for urgent and less than 72 h for regular consultations. Room to support the family was provided in 48.1% of the consultations. The psychiatric report was routinely sent to the general practitioner in 51.7% of the hospitals. CLP teams collaborated on average on three screening protocols or care pathways for psychiatric comorbidity. In 10 hospitals (34.5%), integrated care was established.

Conclusions: Although Flemish CLP services remain heterogeneous and underresourced, they strive to deliver high-quality and quickly accessible multidisciplinary care by fostering collaboration with medical staff and actively involving families and general practitioners in the care process.

We present a case of a patient with mania and psychosis who developed respiratory depression in the emergency department, prompting intubation and intensive care unit admission. While she was in the medical intensive care unit, the embedded psychiatry team optimized psychotropic medications, coordinated sedation strategies, and supported family engagement in her care. Experts in proactive Consultation-Liaison psychiatry discuss how different models of care exist along a spectrum of proactivity and the degree of care integration. We consider the unique challenges of providing proactive care for patients while boarding in the emergency department and explore the strengths and limitations of the embedded model of care, which can enhance the quality of care for individual patients but may limit population-level access when compared with proactive Consultation-Liaison psychiatry. With the implementation and expansion of proactive Consultation-Liaison psychiatry come opportunities for optimizing health equity, in addition to improving clinical and financial outcomes.

We present Mx. A, a 35-year-old nonbinary patient with a complex psychiatric history, including major depressive disorder with psychotic features, attention deficit hyperactivity disorder, and posttraumatic stress disorder, who developed tardive dyskinesia following stimulant (amphetamine/dextroamphetamine) initiation, which improved significantly after discontinuing the stimulant and switching to quetiapine. The case highlights the challenges of managing tardive dyskinesia in patients with overlapping psychiatric conditions and polypharmacy, emphasizing the role of stimulants in exacerbating movement disorders. A review of stimulant-induced movement disorders underscores their association with tics, dyskinesia, and tardive dyskinesia, particularly in attention deficit hyperactivity disorder populations. We discuss treatment strategies, including Vesicular monoamine transporter 2 inhibitors (e.g., valbenazine), antipsychotic switches (e.g., clozapine, quetiapine), and adjunctive therapies (e.g., vitamin E). The report advocates vigilant monitoring, early intervention, and individualized approaches for tardive dyskinesia in high-risk patients.

Background: Parkinson's disease is a chronic, progressive neurodegenerative disorder commonly affecting adults. Demoralization refers to a state characterized by feelings of hopelessness, helplessness, existential distress, a persistent sense of inadequacy, or a perceived inability to meet personal or societal expectations.

Objective: This study aimed to identify factors associated with demoralization in patients with Parkinson's disease.

Methods: We conducted a cross-sectional study using consecutive sampling. Participants were recruited from the neurology ward and outpatient neurology clinic of a single medical center in Taiwan. A total of 120 patients with Parkinson's disease and their caregivers were enrolled. Psychological well-being was assessed using the Demoralization Scale (DS), the Hospital Anxiety and Depression Scale-Depression subscale, the Hospital Anxiety and Depression Scale-Anxiety subscale, the Brief Fatigue Inventory, and the Explanatory Model Interview Catalogue.

Results: Of the 120 patients, 58.3% were male. Higher levels of depression (P = 0.032) and anxiety (P = 0.021) in patients, as well as higher anxiety levels in caregivers (P = 0.015), were significantly associated with demoralization. Structural equation modeling revealed that patient depression severity was significantly associated with both patient anxiety (P < 0.001) and caregiver anxiety (P < 0.001). In addition, both patient and caregiver anxiety were significantly associated with the severity of demoralization in patients (P < 0.001).

Conclusion: Early identification and management of factors related to demoralization may help reduce existential distress, improve coping strategies, and enhance the overall quality of life for patients with Parkinson's disease.

Background: Anorexia nervosa (AN) in older adults presents with medical complexity, psychiatric comorbidity, and diagnostic ambiguity, often overlapping with depression, cognitive decline, or anorexia of aging. A literature base dominated by case reports limits practical guidance for consultation-liaison (C-L) psychiatry.

Objective: To describe key clinical features of AN in older adults, integrating systems-level barriers that shape diagnosis, care transitions, and prognosis.

Methods: We describe 2 late-life AN cases and conducted a systematic review of studies including adults aged ≥60 years with AN defined by the Diagnostic and Statistical Manual of Mental Disorders. Two reviewers independently screened and extracted data and appraised quality using Joanna Briggs Institute tools. Extracted variables included demographics, Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria, psychiatric and medical comorbidities, care setting, and outcomes. We used narrative synthesis with descriptive statistics like n/N, %, median (interquartile range), and ranges to summarize case reports. The AN course was categorized as late-onset (≥60 years), chronic diagnosed, chronic undiagnosed, or recurrence.

Results: Forty publications met criteria: 31 case reports/series, eight cross-sectional studies, and one cohort. Cross-sectional studies showed 3-6% prevalence of disordered eating behaviors with rare AN. Across 47 individually described patients, most were women in their early seventies with severe undernutrition and multimorbidity. Care most commonly occurred on medical units. Nutritional rehabilitation (e.g., supervised meals, enteral feeding) was the most common intervention. Outcomes were mixed, with many patients achieving weight gain, but mortality remained substantial. System-level barriers, such as insurance coverage and access constraints, were not reported in the literature but were prominent in our 2 cases.

Conclusions: In older adults, AN is rare in population samples but severe when clinically detected. The review highlights diagnostic complexity, medical risk, limited psychotherapy/medication detail, and systems barriers central to consultation-liaison practice. Consultation-liaison psychiatrists play a key role in identifying and coordinating treatment for this complex population.

We present a case of a middle-aged man brought to the hospital for altered mental status and hallucinations in a background of chronic alcohol use. Top experts in the consultation-liaison field provide guidance for this commonly encountered clinical case based on their experience and a review of the available literature. Key teaching topics include a differential for and distinguishing features of hallucinations in the setting of alcohol use, risk stratification and selection of agents for alcohol withdrawal management, and prevention of neurological injury in Wernicke-Korsakoff. Specifically, the differential diagnosis for hallucinations in alcohol withdrawal syndrome contains delirium in addition to delirium tremens as many patients do not progress to severe withdrawal syndrome. Symptom triggered protocols for alcohol withdrawal may be less reliable in general hospital settings due to limitations such as confounding medical comorbidities, and selecting an agent for management is based on clinical presentation, properties of the agents, and risk of severe symptoms.

Background: Catatonia is prevalent in the general hospital yet remains under-recognized. Of particular interest is the relationship between delirium and catatonia as recent studies have shown catatonia may co-occur with delirium. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision posits that catatonia does not exist in delirium, although studies have questioned this exclusion.

Objective: To assess the co-occurrence of catatonia and delirium in hospitalized general medical patients and to describe naturalistic treatment outcomes with lorazepam.

Methods: Data from a naturalistic quality improvement project were retrospectively analyzed. All consecutive admissions to 4 general medical units at the University Hospital at Stony Brook were screened within 48 h using the Bush-Francis Catatonia Screening Instrument and the Confusion Assessment Method. The diagnostic threshold on the Bush-Francis Catatonia Screening Instrument was set to 4 signs to increase specificity. The Bush-Francis Catatonia Rating Scale was utilized to monitor severity of positive screens. The quality improvement project included 718 consecutive patient admissions that are reviewed and analyzed in this report.

Results: Approximately 2.2% of the 718 patients met criteria for catatonia. Of the patients with catatonia, 93% also met criteria for co-occurring delirium. The prevalence of delirium in the sample was 24.8%, and 8.4% of patients with delirium also had catatonia. Of those with catatonia and delirium, 43.8% received treatment for catatonia with benzodiazepines. Of those treated, the clinical features of catatonia and delirium remitted in 43% of cases, whereas the signs of catatonia responded to treatment (>50% reduction in Bush-Francis Catatonia Rating Scale) in 57% of cases. All 16 cases of catatonia had 5 or more signs of catatonia, while the majority of the remaining 702 patients had 0-2 signs.

Conclusions: These data provide further evidence that catatonia coexists with delirium, and may respond to lorazepam. We found a bimodal distribution in the number of catatonic signs, suggesting catatonia may be a distinct syndrome among medical patients. Our results suggest that prospective treatment studies are warranted.