consultation-liaison psychiatry – Page 16

Suicide Risk Assessment Update 2019

I updated my suicide risk assessment presentation today in light of new data on suicide risk assessment stratification. It turns out that using such tools might not be supported by the research evidence. That’s not going to stop the use of such tools, which include the Columbia–Suicide Severity Rating Scale, which is in wide use.

I found criticism of these scales in a recently published article in Clinical Psychiatry News, published June 21, 2019, “Why we need another article on suicide contracts,” by Nicholas Badre, MD and Sanjay S. Rao, MD.

For many years now, psychiatrists and other health care professionals have learned that trying to use no-suicide or no-self harm contracts are controversial and don’t prevent suicide. Badre and Rao sound like they’re easing away from that contention although they still say that a thorough clinical suicide risk assessment ought to be done.

Until I saw this article, I was not aware of a recent review of 70 studies showed that: “no individual predictive instrument or pooled subgroups of instruments were able to classify patients as being at high risk of suicidal behavior with a level of accuracy suitable to be used to allocate treatment.”

Carter, G., et al. (2017). “Predicting suicidal behaviours using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales.” Br J Psychiatry 210(6): 387-395.

This was even more interesting because we recently changed our practice regarding suicide risk assessments on the psychiatry consultation service based on relatively new recommendations from the Joint Commission on Accreditation of Hospital Organizations (JCAHO). The Joint Commission favors the risk assessment tools.

Of course I’m not going to second-guess the Joint Commission but after 27 years (counting residency) of struggling to assess suicide risk, I’ve learned that it can hardly be reduced to any single rating instrument.

I have often said to patients that I don’t use no-suicide contracts because they’re too much like promises—and promises are broken every day. That segues into what I prefer which is to work with the patients on developing a safety plan, which I compare to no-suicide contracts by saying “a plan is better than a promise any time.”

Working on the safety plan with patients gives me another way of assessing the strength of my alliance with them and a way to improve it as well as a method for evaluating their ability to formulate a workable way to stay safe that emphasizes their individuality.

On the other hand, the safety plan is no guarantee of safety, any more than the no-suicide contract.

But often enough I’ve gotten the sense that some patients and I have even had a little fun working on suicide safety plans—ironic as that sounds. I find how important pets are, hear little anecdotes about a favorite hobby or goal, aspirations, hopes, and memories of better times when they coped really well.

Listening for understanding to someone who is contemplating suicide or who has attempted suicide is never easy. It’s the hardest thing I do. I can’t say that I’ll miss it when I retire. I have great faith in the next generation of doctors.

New suicide risk assessment presentation

If You Can’t Stand the Heat…

We saw this rabbit in our front yard today, stretched out on the grass under our crabapple tree. It’s 117 degrees this afternoon with the heat index and we won’t get out from under the Excessive Heat Warning until later this evening. Thank goodness for air conditioning. Rabbits don’t have air conditioning and can’t escape the heat.

Sena stands the heat better than I do; she waters the lawn and garden, keeping it beautiful. On the other hand, I felt body-slammed just walking out to get the mail.

The old saying goes, “If you can’t stand the heat, get out of the kitchen.” It means you if you can’t take the pressure of a situation, then you should move and let somebody else take over. It was popularized by President Harry S. Truman, who said the originator of the proverb was Judge Buck Purcell of the Jackson County, Missouri Court—whoever he was.

Anyway, I’m on call this weekend and got to talking with a colleague who is thinking about retirement. We go back a long way in our education and careers. He asked me about what phased retirement is like. I told him I thought if I’d tried to retire outright, I probably would have just come back to work.

That’s a twist on standing the heat. As a psychiatric consultant, I’m like a fireman (get it?) in the general hospital, putting out fires, so to speak, all over the hospital. Most often the problem still tends to be delirium, an acute change in mental status that should be considered a medical emergency rather than a psychiatric problem per se. It’s just one of many crises that I encounter every day. Over 23 years (not counting residency), I learned how to stand the heat in that kitchen. When I retire, somebody else will have to get in there and cook. Speaking of cooking—I still can’t.

I guess I’m mixing my metaphors (fireman and kitchens, etc.). So what? I’m a retiring geezer and I guess I’ve earned the right to mix my metaphors as much as I want.

But in my first year of the 3-year phased retirement contract, I felt a different kind of heat–the heat of trying to find something to do with my unstructured time. It was a struggle for a guy who’s accustomed to being in almost constant motion, climbing up and down 20-30 floors (I hate waiting for elevators) and covering 2-3 miles a day.

The only trouble is—I can’t get out of the kitchen of retirement. I’m getting up there in age and even though most of the time, I seem to leave some of the trainees huffing and puffing getting up the stairs, I know they’ll replace me someday. But I can’t find a replacement to do my retirement time for me.

I have 11 months to go before I retire. I can feel the heat.

Whatever Happened to the Janus Head Logo for ACLP?

I got an email from Don R. Lipsitt, MD yesterday which reminded me of the Janus Head logo for the Academy of Consultation-Liaison Psychiatry (ACLP). It was changed to another sort of nondescript logo several years ago for reasons I didn’t understand.

Dr. Lipsitt is a luminary in C-L Psychiatry and recently published a definitive history of the field, Foundations of C-L Psychiatry: The Bumpy Road to Specialization (2016).

I posted a blog or two about Don and his book in a previous blog, The Practical C-L Psychiatrist. We’ve never formally met. A few years ago, he noticed that I had written about him and his book. I had sent him an email message about it at around the same time the APM was considering the name change for the organization, telling him that I had plugged his book and asking him what he thought of the name change. Incidentally, he thought both of our books made a great package, so I guess I’m allowed to plug mine, strangely titled Psychosomatic Medicine: An Introduction to C-L Psychiatry, editors James Amos and Robert Robinson (2010).

Don expressed his opinion about the name change:

“I feel I have dealt with that at some length in my book. I still feel C-L is most fitting and that the Board made a big mistake naming it PM. Who were they? Any C-L psychiatrists among them? Any Psychosomaticists? Why are not the “complex medically ill” a special population? And why is APA now offering courses on “integrated” care (which is what C-L psychiatry has always been about? The notion that C-L was not declared a specialty because it was considered a skill of ALL psychiatrists (with minimal training), then how do geriatric or child psychiatry become specialties (that all psychiatrists also have training in)? Don’t get me started.”

He considered his book, in large part, a “polemic” against the name “Psychosomatic Medicine.”

Anyway, the ACLP was formerly the Academy of Psychosomatic Medicine (APM) until a couple of years ago when the organization responded robustly to the membership (of which I was one at the time) to abandon the term “Psychosomatic Medicine” and adopt what rank and file practitioners preferred—Consultation-Liaison Psychiatry.

It was a kind of rebranding and it was not the first time the academy had considered a name change. I and a lot of other C-L Psychiatrists cringed at the term “psychosomatic,” not so much because of the word itself in terms of its true denotation, but because of the unfortunate negative connotations it had acquired.

Another luminary of C-L Psychiatry, Dr. Thomas Hackett, MD, wrote about the term “psychosomatic” in the Massachusetts General Hospital: Handbook of general hospital psychiatry: edited by Hackett and Ned Cassem (1978):

“The term ‘psychosomatic service’ has had a variable history. The term generally leaves a bad taste in the mouths of physicians. It reminds them of the 1930s, 1940s, and 1950s, when various psychosomatic schools espoused doctrines linking specific psychological conflicts or unique personality profiles with diseases designated as psychosomatic. Compounding this misunderstanding has been the term’s abuse by the general public, who regard anything psychosomatic as either imaginary or nervous in origin. As a consequence, most people believe that a psychosomatic disease is not to be taken seriously.”

Well, anyway, because of my anecdotage, I’ve strayed a little from my original story about the Janus head logo.

I already mentioned that the logo was abandoned in favor of something that looks like waves and could lead to seasickness. I inquired about the history of the use of the Janus head logo.

In addition to my curiosity about why the logo was changed, I also wondered why it was chosen in the first place and when. According to Don, it was part of the organization’s journal, Psychosomatics, in the late ‘60s and ‘70s. What was interesting is that it was already in use by the Journal of Geriatric Psychiatry when the Psychosomatics editors started using it. However, a conflicting view was that it was not introduced to the cover until 2010. Hmmmm.

I saw the 2012 issue of the APM Newsletter had a pretty funny picture of Drs. Shuster and Rosenstein posing as Janus and the statement “Thank you, Janus. You served us well for over 50 years.” That might put the origin of the logo, at least, around 1962 although my understanding is that APM was started in 1953 (TN Wise, A Tale of Two Societies, Psychosomatics 1995).

Time to say “Hello, again, Janus?”

It’s just my opinion, but because Janus is the ancient god of beginnings and transitions, gates, doorways, endings and time, and typically depicted as two-faced because he looks to the future and the past, I think the symbol is a better image for what C-L Psychiatry has been through over the years.

Anyone for re-rebranding and go retro back to the Janus head logo?

Hoofing it Around the Hospital

Again today, I hoofed it around the hospital. I put 43 floors and a little over 4 miles on my step counter.

I don’t like waiting for elevators so I take the stairs. And a Consult-Liaison Psychiatrist is like a fireman, running all over putting out fires.

I did other things today. I gave the usual lecture on delirium and dementia to the medical students. I notice that as I have gotten older, I tend to tell more anecdotes about my experiences managing delirium in patients on the medical side of the hospital.

I’m in my anecdotage, as I told the students today.

I also lamented the decision by the powers that be to copyright the Montreal Cognitive Assessment (MoCA). The medical students will be able to use it for free, but faculty won’t.

I think that’s ageism. I won’t pay so I won’t use the MoCA anymore.

Back in the Saddle

Well, I’m pretty tapped out, so it’ll be a short post today. I’m back in the saddle, running around the hospital on the psychiatry consult service. This is my last year of phased retirement and in 11 months—I’ll be fully retired.

I put 36 floors and 3 miles on the step counter. I’m feeling every one of those. Sena bought me some banded collar shirts and I’m wearing those instead of a shirt with a necktie. I don’t need a tie bar.

And I don’t worry about a delirious, violent patient strangling me with my necktie.

We had a small scare tonight. We were looking at my total compensation statement (the last one) and got the Sharp Elsi Mate EL-505 vintage calculator out to crunch some figures. The calculator went dead.

I put some new batteries in it, hopeful. It still didn’t work. We’ve had this calculator for over 30 years and it ran more than a decade on the first set of AA batteries.

I tried another pair of batteries. It worked! The vintage calculator lasted longer than the batteries. It’s nice to know that just because something’s old doesn’t mean it’s useless.

That’s all I got.

Informal Bedside Tests for Delirium

Most of this post is an updated redux from years ago about an informal bedside test for delirium called the oral trails test. I learned about it from my senior resident when I was a junior psychiatry resident in training at the VA Medical Center.

There was an elderly patient admitted to the psychiatry unit who was thought to be psychiatrically ill but who actually seemed confused to me and the senior resident. We consulted medicine in order to get him transferred to the general medicine unit but it was tough going. I think the medicine resident disagreed with our clinical impression that he was confused and didn’t think medical transfer was necessary.

Anyway, my senior resident showed me her version of the oral version of the mixed Trails A and B Test for executive function. There is a written form which is part of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). First, she asked him to count from 1 to 7; then she asked him to recite the letters of the alphabet from A to J. She then asked him to try reciting those letters in alternating sequence. Of course, he failed miserably and was eventually transferred to internal medicine. The Trails actually is a paper and pencil test and it looks like a dot to dot game, like the example below:

My senior resident told me she learned the oral Trails test from her senior resident and couldn’t remember anything else about it. I used the test for years but a neuropsychologist criticized the practice, questioning the test’s validity, and rightly so.

Of course, I’d been doing it wrong. You’re supposed to have the patient count to 25, then recite the letters of the alphabet, then recite the numbers and letters in alternating sequence from 1 to 13 and A to M. More than two errors in pairings indicate cognitive impairment.

There are limitations to the verbal Trails and caution is advised in more recent literature, indicating that there are moderate education effects in older patients and that it may be wiser to use both paper and pencil and oral versions together.

Still the search goes on for quick and dirty ways to screen for cognitive impairment in the elderly because this and advanced age are two main risk factors for delirium.

Nowadays, I do the Mini-Cog (shown in the video below) or the Single Question in Delirium (SQiD) test, which just involves asking a family member if the patient seems confused lately.

References:

Mrazik, M., Millis, S., & Drane, D. L. (2010). The oral trail making test: effects of age and concurrent validity. Archives of clinical neuropsychology: the official journal of the National Academy of Neuropsychologists, 25(3), 236–243. doi:10.1093/arclin/acq006

Ricker, J. H., & Axelrod, B. N. (1994). Analysis of an Oral Paradigm for the Trail Making Test. Assessment, 1(1), 47–51. https://doi.org/10.1177/1073191194001001007

Sands, M., Dantoc, B., Hartshorn, A., Ryan, C., & Lujic, S. (2010). Single Question in Delirium (SQiD): testing its efficacy against psychiatrist interview, the Confusion Assessment Method and the Memorial Delirium Assessment Scale. Palliative Medicine, 24(6), 561–565. https://doi.org/10.1177/0269216310371556

My Top Ten YouTube Videos

OK, my top ten YouTube videos are going to get pretty low ratings anyplace else. But where else are you going to see the list but on my blog? In a world where popular videos are viral at a million plus views, I’m way in the back yard.

I wasn’t very picky, of course, because these are the videos I made. I didn’t include any others, especially the ones that were professionally produced. I kept the bar pretty low because I had to. Any video with over 900 views made it to the list, which goes from lowest to highest number of views.

By the way, the only way I could come up with a Top 10 list was to make the bar 900.

10. “Dr. Jim Amos’ Dirty Dozen on Suicide Risk Assessment” published 2012: 940 views

9. “Dr. Jim Amos’ Dirty Dozen on Alcohol Withdrawal Treatment” published 2012: 1,063 views

8. “Dr. Jim Amos’ Dirty Dozen on Catatonia” published 2012: 1,668 views

7. “Mall of America Video” published in 2016: 1,728 views

6. “Dr. Jim Amos’ Dirty Dozen on Interpersonal Psychotherapy” published 2012: 1,840 views

5. “Dr. Jim Amos’ Dirty Dozen on Catatonia, NMS, Serotonin Syndrome” published 2013: 1,960 views

4. “Dirty Dozen on Dr. Allen Frances’ Dozen General Tips on Psychiatric Diagnosis” published 2013: 2,492 views

3. “Pseudobulbar Affect Top Ten” published 2015: 2,613 views

2. “Dr. James Amos’ Dirty Dozen on Somatoform Disorders” published 2012: 8,191 views

1. “Dirty Dozen on Factitious Disorder and Malingering” published 2012: 12,465 views

Now why would a video about abnormal illness behaviors like Factitious Disorder and Malingering be number one?

And why would “Mall of America Video” be my most popular non-work-related video? My wife and I did have a lot of fun there.

I like to think people enjoy “Pseudobulbar Affect Top Ten” because of my superb pseudo-rap acting style—and my hat.

Like my hat?

Quiz Show versus Grand Rounds for Delirium Education Redux

Here’s a redux of one of my blog posts from years ago. There’s not been much change in the data or clinical practice regarding delirium, except we’re even less enthusiastic about using any kind of psychotropic medication to treat delirium, even hypoactive delirium. Try the puzzle.

“So, you want to put on a game show contest to educate clinicians about delirium? Contact David Meagher, a psychiatrist in (where else?) Limerick, Ireland. He reported on this innovative educational workshop in the November 2010 Vol. 3 issue of the Annals of Delirium, the newsletter for the European Delirium Association (EDA). He also published the study which describes the contest in International Psychogeriatrics [1].

The workshop focused on clinician attitudes toward drug therapy for distressed delirious patients. It explored pre-existing attitudes and practice toward the use of medications to manage delirium and exposed participants to a very interactive educational event modeled after a popular TV quiz show. There were two teams (skeptics versus neuroleptics) furnished with a list of statements about delirium pharmacotherapy. The participants later completed a post-workshop questionnaire that explored changes in attitudes as a result of the workshop.

The participants were all experts on the subject and there was a good deal of variability in attitudes and practice. Some of the questions put to the teams involved using antipsychotics prophylactically to prevent delirium, the mechanism of action of antipsychotics, and what role benzodiazepines play in the treatment of non-alcohol withdrawal delirium.

One of the more puzzling findings was that the frequency of antipsychotic use was inversely proportional to the perception of the strength of supporting evidence. In other words, the less they knew about antipsychotics, the more often they used them. Most participants seemed to believe that the principal mechanism of action of antipsychotics is sedation, despite the lack of supporting evidence.

Some clinicians used antipsychotics to relieve the stress of caregivers rather than that of delirious patients, an example of patients getting the right treatment for the wrong reasons as observed by Meagher—and many of us in the field.

The workshop also highlighted the tendency of clinicians to focus on risk management rather than effective therapeutic intervention in the management of delirious patients with disruptive behavior and severe distress. This mainly relates to focus on the potential adverse effects of antipsychotics such as extrapyramidal side effects, metabolic, and cerebrovascular effects.

The quiz show activity was fun and challenging. The device of dividing the participants into two small teams with larger audience participation cut down on the anxiety that could be provoked by giving the “wrong answer”. The questions were true/false and didn’t always have clear right or wrong answers. It was highly interactive, a component of continuing medical educational (CME) activities that is increasingly encouraged because it’s more likely to lead to changes in clinician attitude and practice. The one time Grand Rounds CME “seat time” is going the way of the dinosaur.

So a couple of findings from the quiz show post-activity questionnaire were that clinicians were more likely to use antipsychotics prophylactically and to use antipsychotics to manage hypoactive delirium.

Our delirium intervention project group members are not quite as enthusiastic yet about these two interventions. We’re a bit more inclined at least initially to focus on non-pharmacologic multicomponent strategies such as the example below:

Minimize the use of immobilizing catheters, intravenous lines, and physical restraints
Avoid immobility, early mobilization
Monitor nutrition
Provide visual and hearing aids
Monitor closely for dehydration
Control pain
Monitor fluid-electrolyte balance
Monitor bowel and bladder functioning
Review medications
Reorient communications with the patient
Place an orientation board, clock, or familiar objects (i.e., family photographs) in patient rooms
Encourage cognitively stimulating activities such as word puzzles
Facilitate sleep hygiene measures, including relaxation music or tapes at bedtime, warm drinks, and gentle massage
Minimize noise and interventions at bedtime, e.g., by rescheduling medication times

But I’m just as enthusiastic about interactive educational methods to engage learners in order to build a culture more likely to produce champions who will lead the delirium prevention effort—try the delirium multicomponent crisscross puzzle below. The clues are contained in the list of multicomponent tactics above.”

Meagher, D.J., Impact of an educational workshop upon attitudes towards pharmacotherapy for delirium. Int Psychogeriatr, 2010. 22(6): p. 938-46.

SQiD vs CAM Redux

This was a blog post I wrote back in 2011 on another blog, The Practical C-L Psychiatrist. SQiD is short for Single Question in Delirium and it’s a very short and effective screen for delirium, if you have a reliable informant. I also mention the Edinburgh Delirium Test Box (EDTB). It has been further developed into a smartphone app.

“The November Vol. 3 issue of the Annals of Delirium published a summary of an interesting study of a Single Question in delirium (SQiD) as a screen for delirium compared to the Confusion Assessment Method (CAM), the Memorial Delirium Assessment Scale (MDAS) and a psychiatrist interview[1].

The question “Do you think (name of patient) has been more confused lately?” was put to a friend or relative of 21 patients. Compared with psychiatric interview, the SQiD achieved a sensitivity and specificity of 80% (95% CI 28.3-99.49%) and 71% (41.90-91.61%) respectively. The CAM demonstrated a negative predictive value (NPV) of 80% (51.91-95.67%) and the SQiD showed an NPV of 91% (58.72-99.77%). The CAM in the study had only a 40% sensitivity used by minimally trained clinical users.

The negative predictive value of a test tells you how likely it is that you actually don’t have the condition or disease. It’s defined as the number of true negatives (people who test negative who are not affected) divided by the total number of patients who test negative and it varies with test sensitivity, test specificity, and disorder prevalence. The sensitivity of a test is how accurately it detects patients who are positive for the disorder (in this case delirium). If 100 patients are positive for the disorder, then a test that is 80% sensitive will detect 80 of those cases and miss 20 actual cases of the disorder. Specificity is defined as how accurately a test detects patients who do not have the disorder. In our delirium example, if 100 patients are free of the disorder, then a test that is 71% specific will correctly tell 71 of those people that they are not affected and will incorrectly tell 29 that they have the disorder when they don’t.

This seems to suggest that a single question screening question packs a fair punch compared to screening instruments and psychiatric interview for identifying delirium. The CAM takes a few minutes to complete and requires training to achieve optimal identification rates.

The authors suggest the SQiD deserves further study and their results seem to support the conclusion. The study is limited by small sample size, but intuitively the premise is appealing. This is one of the quickest tests for delirium applicable and can be applied by almost anyone.

Single question screening exams for depression are not unheard of so there is precedence for the SQiD. You just have to be careful about what you say in front of patients and families. “Go ahead and run the squid on Mr. Jones” could raise a few eyebrows.

This is possibly a low tech solution in a pinch when the CAM forms file is empty or the battery is low on the Edinburgh Delirium Test Box (EDTB)[2]. The EDTB is a more high-tech solution to testing for what neuropsychologists believe what one of the main abnormalities is in delirium—lack of sustained attention. It’s a computerized neuropsychological testing device.

And that face-off would be called SQiD versus Box.”

References:

1. Sands, M., et al., Single Question in Delirium (SQiD): testing its efficacy against psychiatrist interview, the Confusion Assessment Method and the Memorial Delirium Assessment Scale. Palliative Medicine, 2010. 24(6): p. 561-565.

2. Brown, L.J.E., et al., Detecting deficits of sustained visual attention in delirium. Journal of Neurology, Neurosurgery & Psychiatry.

Coach’s Corner: Somatoform Illness

This is a short Coach’s Corner video on somatoform and related abnormal illness behaviors which prompt physicians to request psychiatric consultation. Medically unexplained physical symptoms are not rare in the hospital and in medical clinics.

The general idea is to remember Stephen Covey’s caution about effectiveness and efficiency, which is that you have a lot better chance being effective rather than efficient with people.

“With people, slow is fast and fast is slow.”
Stephen Covey

The point is that it’s very important to listen for understanding and to validate pain and suffering. That means sitting with patients and taking time to hear what they tell you.

There is an excellent presentation on conversion disorder (also known as functional neurological disorder) on the National Neuroscience Curriculum Initiative (NNCI) web site. It’s very helpful for clinicians and patients.