Research

Abstract

We present Academy of Consultation Liaison Psychiatry (ACLP) best practice guidance on depression in Solid Organ Transplant (SOT) recipients which resulted from the collaboration of ACLP's Transplant Psychiatry Special Interest Group (SIG) and Guidelines and Evidence-Based Medicine Subcommittee. Depression (which in the transplant setting may designate depressive symptoms or depressive disorders) is a frequent problem among SOT recipients. Following a structured literature review and consensus review process, the ACLP Transplant psychiatry SIG proposes recommendations for practice: all organ transplant recipients should be screened routinely for depression. When applicable, positive screening should prompt communication with the mental health treating provider or a clinical evaluation. If the evaluation leads to a diagnosis of depressive disorder, treatment should be recommended and offered. The recommendation for psychotherapy should consider the physical and cognitive ability of the patient to maximize benefit. First-line antidepressants of choice are escitalopram, sertraline, and mirtazapine. Treating depressive disorders prior to transplantation is recommended to prevent post-transplant depression. Future research should address the mechanism by which transplant patients develop depressive disorders, the efficacy and feasibility of treatment interventions (both pharmacological and psychotherapeutic, in person and via telemedicine), and the resources available to transplant patients for mental health care.

View details for DOI 10.1016/j.jaclp.2023.03.007

View details for PubMedID 37003570

View details for Web of Science ID 000870796603104

Abstract

Among the potential complications of allogeneic hematopoietic stem cell transplantation (HSCT), graft-versus-host disease (GVHD) is common and associated with significant physical and psychosocial symptom burden. Despite substantial advances in GVHD treatment, the global immune suppression that frequently accompanies GVHD treatment also contributes to high rates of physical and emotional suffering and mortality. The complex manifestations of GVHD and its treatment warrant a multidisciplinary team-based approach to managing patients' multi-organ system comorbidities. A biobehavioral framework can enhance our understanding of the complex association between medications, physical symptoms, and psychosocial distress in patients with GVHD. Hence, for this perspective, we highlight the importance of addressing both the physical and psychosocial needs experienced by patients with GVHD and provide guidance on how to approach and manage those symptoms and concerns as part of comprehensive cancer care.

View details for DOI 10.1016/j.jtct.2024.05.024

View details for PubMedID 39370233

Abstract

Psychosocial health predicts and contributes to medical outcomes for patients undergoing hematopoietic stem cell transplantation (HSCT). Yet, there are no standards for psychosocial assessments or support for both patients and caregivers across the care continuum. To examine the current state of psychosocial care, clinicians were sent a survey of their psychosocial assessment practices for patients and caregivers undergoing HSCT via the Listservs of professional organizations. Descriptive statistics and bivariate analyses were performed to summarize the findings. While 96% of participants reported routine pre-HSCT psychosocial assessment of patients, only 10.6% routinely used a validated transplant risk-assessment measure. Just 27% routinely performed follow-up psychosocial assessments. In contrast, only 47% of participants routinely assessed the psychosocial needs of family caregivers pre-HSCT, and 13% routinely performed follow-up assessments for caregivers. Most (90%) reported social workers were the primary providers of assessments. While patient-report measures were used for evaluation, the majority of assessments were clinical interviews. No significant differences were found between programs that treated adult and pediatric patients versus those only treating adult patients. Our findings highlight the lack of standard psychosocial practices for patients and family caregivers undergoing HSCT and we offer recommendations to fill this gap.

View details for DOI 10.21203/rs.3.rs-3044597/v1

View details for PubMedID 37461551

View details for PubMedCentralID PMC10350176

View details for Web of Science ID 000947888900046

View details for Web of Science ID 000947888900005

View details for Web of Science ID 000947888900002

Abstract

These NCCN Guidelines for Distress Management discuss the identification and treatment of psychosocial problems in patients with cancer. All patients experience some level of distress associated with a cancer diagnosis and the effects of the disease and its treatment regardless of the stage of disease. Clinically significant levels of distress occur in a subset of patients, and identification and treatment of distress are of utmost importance. The NCCN Distress Management Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights describe updates to the NCCN Distress Thermometer (DT) and Problem List, and to the treatment algorithms for patients with trauma- and stressor-related disorders.

View details for DOI 10.6004/jnccn.2023.0026

View details for PubMedID 37156476

Abstract

In the past decade, the demand for home-based care has been amplified by the COVID-19 pandemic. Home-based care has significant benefits for patients, their families, and healthcare systems, but relies on the often invisible workforce of family and friend caregivers who shoulder essential health care responsibilities often with inadequate training and support. Hematopoietic cell transplantation (HCT), a potentially curative but intensive treatment for many patients with blood disorders, is increasingly offered in home-based care settings and necessitates the involvement of family caregivers for significant patient care responsibilities. However, guidelines for supporting and preparing HCT caregivers to effectively care for their loved ones at home have not yet been established. Informed by extant literature and our collective experiences as clinicians and researchers who care for diverse patients with hematologic malignancies undergoing HCT, we provide considerations and recommendations to better support and prepare family caregivers in home-based HCT and, by extension, family caregivers supporting patients with other serious illnesses at home. We suggest tangible ways to screen family caregivers for distress and care delivery challenges, educate and train them to prepare for their caregiving role, and create an infrastructure of support for family caregivers within this emerging care delivery model.

View details for DOI 10.1016/j.jtct.2022.12.014

View details for PubMedID 36572386

View details for PubMedCentralID PMC9780643

View details for DOI 10.1182/blood-2022-168229

View details for Web of Science ID 000893223205100

View details for Web of Science ID 000922594700300

Abstract

Chimeric antigen receptor (CAR) T-cell therapy has demonstrated remarkable clinical responses in hematologic malignancies. Recent advances in CAR T-cell therapy have expanded its application into other populations including older patients and those with central nervous system and solid tumors. Although its clinical efficacy has been excellent for some malignancies, CAR T-cell therapy is associated with severe and even life-threatening immune-mediated toxicities, including cytokine release syndrome (CRS) and neurotoxicity. There is a strong body of scientific evidence highlighting the connection between immune activation and neurocognitive and psychological phenomena. To date, there has been limited investigation into this relationship in the context of immunotherapy. In this review, we present a biobehavioral framework to inform current and future cellular therapy research and contribute to improving the multidimensional outcomes of patients receiving CAR T-cell therapy.

View details for DOI 10.1016/j.jtct.2022.09.029

View details for PubMedID 36208728

Abstract

Converging evidence indicates that impairments in executive function and information-processing speed limit quality of life and social reentry after moderate-to-severe traumatic brain injury (msTBI). These deficits reflect dysfunction of frontostriatal networks for which the central lateral (CL) nucleus of the thalamus is a critical node. The primary objective of this feasibility study was to test the safety and efficacy of deep brain stimulation within the CL and the associated medial dorsal tegmental (CL/DTTm) tract.Six participants with msTBI, who were between 3 and 18 years post-injury, underwent surgery with electrode placement guided by imaging and subject-specific biophysical modeling to predict activation of the CL/DTTm tract. The primary efficacy measure was improvement in executive control indexed by processing speed on part B of the trail-making test.All six participants were safely implanted. Five participants completed the study and one was withdrawn for protocol non-compliance. Processing speed on part B of the trail-making test improved 15% to 52% from baseline, exceeding the 10% benchmark for improvement in all five cases.CL/DTTm deep brain stimulation can be safely applied and may improve executive control in patients with msTBI who are in the chronic phase of recovery.ClinicalTrials.gov identifier: NCT02881151 .

View details for DOI 10.1038/s41591-023-02638-4

View details for PubMedID 38049620

View details for PubMedCentralID 8126422

View details for DOI 10.1016/j.jaclp.2023.11.226

View details for Web of Science ID 001161339100210

Abstract

Delirium is the most prevalent neuropsychiatric syndrome experienced by patients admitted to inpatient clinical units, occurring in at least 20% of medically hospitalized patients and up to 85% of those admitted to critical care units. Although current guidelines recommend the implementation of universal prevention strategies, the use of management strategies largely depend on constant surveillance and screening. This allows for the timely diagnosis and the correction of its underlying causes and implementation of management strategies.It was to adapt and analyze the Spanish adaptation of the Stanford Proxy Test for Delirium (S-PTDsv) instrument for its use among Spanish-speaking populations. The S-PTD is an instrument consisting of 13 observational items to be completed by a clinician observer, usually the patient's nurse. The completion of the questionnaire takes about one minute and does not require the active participation of the person evaluated, which has important clinical advantages compared to other available instruments (e.g., the Confusion Assessment Method [CAM]).The psychometric properties of the S-PTDsv were evaluated in a population of 123 patients, using a quantitative, cross-sectional design. All subjects were over 18 years of age and hospitalized in various inpatient medico-surgical and Intensive care Unit services, either to the Barcelona Clinical Hospital (Barcelona, Spain) or the UC-Christus Health Network Clinical Hospital (Santiago, Chile, S.A.). The ultimate diagnosis of delirium was made by a member of the Psychiatry Consult Service, by means of an independent neuropsychiatric evaluation based on the 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria, published in 2013 and is the latest version of the diagnostic manual. All study tests were performed by study personnel who were blinded to each other's test results and within an hour of each other.In the ROC analysis, the S-PTDsv demonstrated excellent classification qualities when compared with the DSM-5, as the classification gold-standard. Using a cut-off point of ≥3, the S-PTDsv had a sensitivity of 94% and a specificity of 97%. The AUC indicator was equal to 0.95, suggesting the S-PTDsv has an excellent overall performance in accurately identifying cases of Delirium. Accordingly, the S-PTDsv's positive predictive value (PPV) = 0.93, and the negative predictive value (NPV) = 0.97. The internal reliability measured with Cronbach's Alpha was 0.96. Confirmatory factor analysis revealed a one-dimensional structure with high loadings (>0.72), demonstrating that all items similarly contribute to the total diagnostic dimension, suggesting adequate construct validity. This provided evidence of convergent validity.The performance of the S-PTDsv, as compared to a blinded neuropsychiatric assessment based on DSM-5, indicates that it is an effective instrument for the detection of Delirium, in the Spanish speaking populations. These results are comparable and consistent with previously published studies in the English language version.

View details for DOI 10.1016/j.jaclp.2023.09.004

View details for PubMedID 37806639

View details for DOI 10.1016/j.jpsychores.2023.111282

View details for Web of Science ID 001041062900048

View details for Web of Science ID 000999622600001

Abstract

Background Delirium is a syndrome of acute brain failure that represents a change from an individual's baseline cognitive functioning characterized by deficits in attention and multiple aspects of cognition that fluctuate in severity over time. The symptomatic management of delirium's behavioral manifestations remains difficult. The alpha-2 agonists, dexmedetomidine and clonidine, are efficacious, but their potential cardiovascular adverse effects limit their utilization. Guanfacine is an oral alpha-2 agonist with a lower potential for such adverse outcomes; however, its use in delirium has not been studied. Methods A retrospective descriptive analysis of guanfacine for managing hyperactive or mixed delirium at Tampa General Hospital from January 2020 to October 2020 was conducted. The primary outcome was the time reduction in acute sedative administration. Secondary outcomes included renewed participation in physical therapy or occupational therapy (PT/OT), decreased opioid use, and an incidence of cardiovascular adverse effects. Results One hundred forty-nine patients were identified as having received guanfacine for managing delirium during the study period. All experienced a reduction in acute sedative use after the initiation of guanfacine. In 93 patients receiving PT/OT and no longer participating due to behavioral agitation, 74% had a documented renewal of services within four days. Of 112 patients on opioids, 70% experienced a 25% reduction in opioid administration within four days. No patients experienced consecutive episodes of hypotension that required a change in their clinical care. Two patients experienced a single episode of consecutive bradycardia that led to the discontinuation of guanfacine. Conclusions Based on our retrospective study, guanfacine is a well-tolerated medication for the management of delirium. Even in medically and critically ill patients, cardiovascular adverse events were rare with guanfacine. Patients treated with guanfacine experienced decreased acute sedative use for behavioral agitation. Additionally, patients treated with guanfacine received fewer opioids and were better able to participate in PT/OT. Future studies with prospective, randomized, placebo-controlled designs are warranted to evaluate this promising intervention for delirium further.

View details for DOI 10.7759/cureus.33393

View details for PubMedID 36751225

Abstract

Consultation-liaison (CL) psychiatrists are frequently asked to consult on various abnormal movements(1). CL psychiatrists can be instrumental in aiding the primary teams to identify and manage these movement disorders. In this manuscript, we provide an illustrative case of a patient presenting with myoclonus and offer a review on this important topic. Myoclonus accompanied by delirium represents a rare post-transplant complication and can be associated with heightened morbidity and mortality. The incidence of this complication in solid organ transplant (SOT) recipients is scarcely documented, and its pathophysiology remains inadequately understood. Potential etiologies in the intensive care unit (ICU) are numerous and likely multifactorial. The literature lacks detailed descriptions of the correlation and association between myoclonus and uremia. Management of this condition requires a multimodal approach, focusing on resolving underlying metabolic disturbances and providing symptomatic treatment.This manuscript describes the clinical presentation of myoclonus in a liver transplant recipient accompanied by delirium and precipitated by uremia. We aim to highlight the diagnostic and therapeutic complexities, help providers distinguish myoclonus from other movement disorders, and aid appropriate management.We present a case of acute myoclonus in an elderly female liver transplant recipient precipitated by uremia and improved after continuous renal replacement treatment. In addition, we conducted a systematic review utilizing EMBASSE and PubMed of reported cases of myoclonus, delirium, and/or encephalopathy accompanied by uremia. We included 12 manuscripts in our review and discussed their findings.CL psychiatrists are frequently consulted for a range of movement disorders in the ICU, including myoclonus. Accurate diagnosis and identification of contributing etiologies are critical in these cases. Management typically involves addressing the underlying disorder, such as using dialysis for uremia, alongside symptomatic treatment with benzodiazepines to mitigate the frequency and amplitude of myoclonus. This approach helps to alleviate both the physical burden and psychological distress associated with the condition. This case underscores the pivotal role of the CL psychiatrist within a complex multidisciplinary team, contributing to diagnostic precision and optimization of management strategies for movement disorders.

View details for DOI 10.1016/j.jaclp.2024.07.004

View details for PubMedID 39074779

View details for DOI 10.1016/j.jpsychores.2024.111757

View details for Web of Science ID 001276847900057

Abstract

Consultation-liaison (CL) psychiatrists frequently address dyspnea in intensive care unit (ICU) patients. Dyspnea is common in this patient population, but is frequently misunderstood and underappreciated in non-communicative ICU patients.This paper provides an updated review on dyspnea specifically in the ICU population, including its pathophysiology and management, pharmacological and non-pharmacological, aimed at CL psychiatrists consulting in ICU.A literature review was conducted with PubMed, querying published articles for topics associated with dyspnea and dyspnea-associated anxiety (DAA) in ICU patient populations. When literature in ICU populations was limited, information was deduced from dyspnea and anxiety management from non-ICU populations. Articles discussing the definition of dyspnea, mechanistic pathways, screening tools, and pharmacologic and non-pharmacologic management were included.A reference guide was created to help CL psychiatrists and intensivists in the screening and treatment of dyspnea and DAA in critically ill patients.Dyspnea is frequently associated with anxiety, prolonged days on mechanical ventilation, and worse quality of life after discharge. It can also increase the risk of posttraumatic stress disorder post ICU discharge. However, it is not routinely screened for, identified, or addressed in the ICU. This manuscript provides an updated review on dyspnea and DAA in the ICU population, including its pathophysiology and management, and offers a useful reference for CL psychiatrists to provide treatment recommendations.

View details for DOI 10.1016/j.jaclp.2023.11.001

View details for PubMedID 37952697

View details for DOI 10.1016/j.jaclp.2023.11.667

View details for Web of Science ID 001161339100187

Abstract

Tacrolimus is the most common immunosuppressant used after transplant, yet it can result in moderate-to-severe neurotoxicity in up to 32% of patients. Signs of neurotoxicity can vary from mild (tremor or headache) to severe (posterior reversible encephalopathy syndrome or psychosis. Prompt recognition and management is needed to lead to symptom resolution.The objective of this study is to describe the clinical presentation of tacrolimus-induced psychosis, a type of tacrolimus-inducted neurotoxicity, and distinguish it from other central nervous system disturbances, including delirium.We present a case of delayed onset tacrolimus-induced psychosis with focus on unique clinical features and management strategies. We conducted a systematic review of cases of tacrolimus-induced psychosis using the PubMed database and included 15 manuscripts in our review.Tacrolimus-induced psychosis is a unique presentation of tacrolimus-related neurotoxicity and can present without the cardinal symptoms of delirium. The data on isolated psychotic symptoms are limited with current literature focusing on more common presentations of tacrolimus-induced neurotoxicity, such as delirium and tremor. Development of psychosis can occur later in the treatment course and at normal tacrolimus serum levels. It can improve with antipsychotic therapies, but primary management should include cross-titration to an alternate immunosuppressant regimen.

View details for DOI 10.1016/j.jaclp.2023.09.002

View details for PubMedID 37778461

View details for Web of Science ID 000672228200020

View details for Web of Science ID 000575913300013

View details for Web of Science ID 000549388900009

View details for Web of Science ID 000519299000002

Abstract

Despite being a debilitating, costly, and potentially life-threatening condition, depression is often underdiagnosed and undertreated. Previsit Patient Health Questionnaire-9 (PHQ-9) may help primary care health systems identify symptoms of severe depression and prevent suicide through early intervention. Little is known about the impact of previsit web-based PHQ-9 on patient care and safety.We aimed to investigate differences among patient characteristics and provider clinical responses for patients who complete a web-based (asynchronous) versus in-clinic (synchronous) PHQ-9.This quality improvement study was conducted at 33 clinic sites across 2 health systems in Northern California from November 1, 2020, to May 31, 2021, and evaluated 1683 (0.9% of total PHQs completed) records of patients endorsing thoughts that they would be better off dead or of self-harm (question 9 in the PHQ-9) following the implementation of a depression screening program that included automated electronic previsit PHQ-9 distribution. Patient demographics and providers' clinical response (suicide risk assessment, triage nurse connection, medication management, electronic consultation with psychiatrist, and referral to social worker or psychiatrist) were compared for patients with asynchronous versus synchronous PHQ-9 completion.Of the 1683 patients (female: n=1071, 63.7%; non-Hispanic: n=1293, 76.8%; White: n=831, 49.4%), Hispanic and Latino patients were 40% less likely to complete a PHQ-9 asynchronously (odds ratio [OR] 0.6, 95% CI 0.45-0.8; P<.001). Patients with Medicare insurance were 36% (OR 0.64, 95% CI 0.51-0.79) less likely to complete a PHQ-9 asynchronously than patients with private insurance. Those with moderate to severe depression were 1.61 times more likely (95% CI 1.21-2.15; P=.001) to complete a PHQ-9 asynchronously than those with no or mild symptoms. Patients who completed a PHQ-9 asynchronously were twice as likely to complete a Columbia-Suicide Severity Rating Scale (OR 2.41, 95% CI 1.89-3.06; P<.001) and 77% less likely to receive a referral to psychiatry (OR 0.23, 95% CI 0.16-0.34; P<.001). Those who endorsed question 9 "more than half the days" (OR 1.62, 95% CI 1.06-2.48) and "nearly every day" (OR 2.38, 95% CI 1.38-4.12) were more likely to receive a referral to psychiatry than those who endorsed question 9 "several days" (P=.002).Shifting depression screening from in-clinic to previsit led to a dramatic increase in PHQ-9 completion without sacrificing patient safety. Asynchronous PHQ-9 can decrease workload on frontline clinical team members, increase patient self-reporting, and elicit more intentional clinical responses from providers. Observed disparities will inform future improvement efforts.

View details for DOI 10.2196/50192

View details for PubMedID 38712997