Georgina Garcia

Psychiatric manifestations of anti-NMDA receptor encephalitis: neurobiological underpinnings and differential diagnostic implications.

OBJECTIVE Anti-N-methyl-d-aspartate receptor (NMDA-R) encephalitis is a recently discovered disorder with prominent psychiatric manifestations that is often misdiagnosed. The objective of this review is to raise awareness of the disorder among psychiatrists and to expand upon the diagnostic considerations that arise in the context of the neurobiology and symptomatology of this disorder. We also aim to examine the similarities in terms of symptoms and underlying neurobiology between anti-NMDA-R encephalitis and schizophrenia-spectrum illnesses. METHODS The information presented will reflect a review of the literature of the symptomatology and pathophysiology of anti-NMDA-R encephalitis and the role of the NMDA-R in both anti-NMDA-R encephalitis and schizophrenia-spectrum illnesses. RESULTS The studies reviewed highlight the role of the NMDA-R in both anti-NMDA-R encephalitis and schizophrenia in terms of symptom presentation and neurobiology. Studies have also begun to identify involvement of NMDA-R antibodies in patients diagnosed with schizophrenia. CONCLUSIONS There is an increasing need for psychiatrists to become aware of the disorder and consider it in their differential diagnosis, as they are often the first to be consulted on patients with anti-NMDA-R encephalitis. The similarities identified between anti-NMDA-R encephalitis and schizophrenia-spectrum illnesses also raise questions about a common underlying pathophysiology particularly in regard to the NMDA-R.

Depression, illness severity, and healthcare utilization in cystic fibrosis

Cystic fibrosis (CF) is an illness associated with high healthcare utilization and healthcare costs, even when compared to other chronic illnesses. In a variety of medical populations, depression has been found to be associated with lower adherence and poorer medical outcomes. The current study is a retrospective chart review of a matched set of 40 patients with CF, half with and half without a depressive disorder diagnosis. Participants were matched on the basis of their age, gender and lung function, and compared in terms of their illness severity (lung function and weight), medical adherence, and healthcare utilization during the year prior to and following diagnosis of depression and a comparable time period for the non‐depressed group. Results show an association between depression and BMI, with only the depressed group showing significant decreases in the year following their depressive disorder diagnosis (from a mean BMI z‐score of −0.48 to −1.04). Depression was also strongly associated with greater healthcare utilization and healthcare costs relative to those of comparably medically ill controls, in that depressed youth were hospitalized at over three times the rate of non‐depressed youth, and their healthcare costs were more than four times higher (mean number of admissions per year for the depressed group of 4.00 vs. 1.20 for the non‐depressed group; mean annual costs of

Vitamin D and Depressive Symptoms in Children with Cystic Fibrosis

280,000 for the depressed vs.

Management of Psychotropic Medication Side Effects in Children and Adolescents

60,116 for the non‐depressed). These findings highlight the importance of addressing the mental health needs of chronically ill patients as a path to better health outcomes and decreasing need for medical services. Pediatr Pulmonol. 2014; 49:1177–1181.

Development of the Vanderbilt Assessment for Delirium in Infants and Children to Standardize Pediatric Delirium Assessment By Psychiatrists

BACKGROUND Vitamin D deficiency has been hypothesized to play a role in the development of depression. Hypovitaminosis D is almost universal in patients with cystic fibrosis (CF). No studies to date have explored associations between serum concentrations of 25-hydroxyvitamin D (25(OH)D), a standard measure of vitamin D, and depression in patients with CF. OBJECTIVE This pilot study aimed to explore the relationship between 25(OH)D and the presence of depressive symptoms among youth with CF. METHODS A cross-sectional study was conducted at an ambulatory Cystic Fibrosis Center clinic. Serum 25(OH)D and Childrens Depression Inventory (CDI) scores were analyzed from 38 youths with CF ages 7-17 years. Child depressive symptoms were measured using the CDI, with scores above 12 indicating a significant level of depressive symptoms. Serum 25(OH)D concentration were measured using the liaison 25 OH vitamin D assay. Insufficient vitamin D status was defined as a circulating 25(OH)D concentration less than 30 ng/mL. RESULTS Insufficient vitamin D levels were found in 59% of patients; 28% of patients had significant levels of depressive symptoms on the CDI (scores >12). Serum 25(OH)D was negatively associated with CDI scores (r = -0.55; p < 0.001), and the group of patients with insufficient 25(OH)D levels indeed reported significantly more depressive symptoms (t = 4.26; p < 0.001). CONCLUSIONS 25(OH)D insufficiency was associated with depressive symptoms in this cohort of youth with CF. Future rigorous studies investigating vitamin D and depression in CF are warranted with larger sample sizes using confirmatory methods to diagnose depressive disorders.

Mental Health Screening of Medically-Admitted Patients With Cystic Fibrosis

This article is a review of several of the most concerning side effects of psychotropic medications in children and adolescents. An emphasis is placed on review of the prevalence, presentation, monitoring, and evidence-based management of these side effects.

Parent and Young Adult Satisfaction with Psychiatry Consultation Services in a Children's Hospital

BACKGROUND Pediatric delirium assessment is complicated by variations in baseline language and cognitive skills, impairment during illness, and absence of pediatric-specific modifiers within the Diagnostic and Statistical Manual of Mental Disorders delirium criterion. OBJECTIVE To develop a standardized approach to pediatric delirium assessment by psychiatrists. METHODS A multidisciplinary group of clinicians used Diagnostic and Statistical Manual criterion as the foundation for the Vanderbilt Assessment for Delirium in Infants and Children (VADIC). Pediatric-specific modifiers were integrated into the delirium criterion, including key developmental and assessment variations for children. The VADIC was used in clinical practice to prospectively assess critically ill infants and children. The VADIC was assessed for content validity by the American Academy of Child and Adolescent Psychiatry Delirium Special Interest Group. RESULTS The American Academy of Child and Adolescent Psychiatry-Delirium Special Interest Group determined that the VADIC demonstrated high content validity. The VADIC (1) preserved the core Diagnostic and Statistical Manual delirium criterion, (2) appropriately paired interactive assessments with key criterion based on development, and (3) addressed confounders for delirium. A cohort of 300 patients with a median age of 20 months was assessed for delirium using the VADIC. Delirium prevalence was 47%. CONCLUSION The VADIC provides a comprehensive framework to standardize pediatric delirium assessment by psychiatrists. The need for consistency in both delirium education and diagnosis is highlighted given the high prevalence of pediatric delirium.

Survey of collaborative mental health providers in cystic fibrosis centers in the United States

BACKGROUND Multi-national studies have identified an increased risk for depression and anxiety among the cystic fibrosis population. People with cystic fibrosis and depression have decreased lung function, adherence, and quality of life, and increased health care utilization. This is a pilot study of mental health screening and referral of patients with cystic fibrosis in a large tertiary medical center. OBJECTIVE Patients with a diagnosis of cystic fibrosis aged 8 and older, medically admitted to a tertiary hospital, were screened for eligibility and offered mental health screening for depression and anxiety. METHODS Patients indicating elevated rates of anxiety, depression, or suicidal ideation were offered a psychiatric consultation, and all participants were offered mental health referrals. Health-related outcomes were gathered via medical record review. RESULTS The pediatric population showed elevated rates/at risk of depression (17%), anxiety (22%) and clinically-elevated depression (5%), and anxiety (11%). Twenty-two percent of the youth reported suicidal ideation. The adult population reported mild rates of depression (11%), anxiety (28%), and suicidality (11%). The mental health screening process resulted in 1 mental health referral, 16 patients eligible for psychiatric consultation, and 4 completed psychiatric consultations. DISCUSSION This study represents a pilot mental health screening in the inpatient medical setting. The results indicate an elevated rate of depression, anxiety, and suicidal ideation, and a protocol for responding to elevated responses via psychiatric consultation. This study indicates the need for further exploration of implementation of mental health screening, rapid response to suicidal ideation, referral process, and treatment interventions.