James R. Rundell

Essential articles on collaborative care models for the treatment of psychiatric disorders in medical settings: a publication by the academy of psychosomatic medicine research and evidence-based practice committee.

BACKGROUND Collaborative care interventions for psychiatric disorders combine several components integrated into the medical setting: (1) systematic psychiatric assessment, (2) use of a nonphysician care manager to perform longitudinal symptom monitoring, treatment interventions, and care coordination, and (3) specialist-provided stepped-care recommendations. Collaborative care interventions have now been evaluated in a wide spectrum of care settings and offer great promise as a way of increasing quality of patient care, improving health of populations, and reducing health care costs. METHODS A systematic search of PubMed/MEDLINE databases was performed for publications between January 1970 and May 2013 to identify articles describing collaborative care and related interventions. Identified articles were then evaluated independently by multiple reviewers for quality and importance; additional articles were identified by searching reference lists and through recommendations of senior content-matter experts. The articles considered to be both of high quality and most important were then placed into categories and annotated reviews performed. RESULTS Over 600 articles were identified of which 67 were selected for annotated review. The results reported in these articles indicate that collaborative care interventions for psychiatric disorders have been consistently successful in improving key outcomes in both research and clinical intervention studies; cost analyses also suggest that this model is cost effective. CONCLUSIONS Collaborative care models for psychiatric disorders are likely to serve an increasingly large role in health care given their effect on patient and population outcomes and their focus on integration of care.

A prospective study of psychiatric aspects of early HIV disease in women

Few studies of psychiatric morbidity associated with HIV disease have included women. The authors prospectively studied a cohort of HIV-seropositive women, none of whom had AIDS, to assess changes in their psychiatric status over time. All seropositive women admitted to the U.S. Air Forces HIV evaluation unit for comprehensive evaluations since 1987 were eligible for enrollment in an open-ended prospective study. Forty-three women without AIDS enrolled between 1987 and 1991 (83% of those eligible), 29 of whom have been interviewed at least twice. The Structured Clinical Interview for DSM-III-R and a semistructured interview were administered to assess psychiatric diagnoses, suicidality, sexual functioning, affective status, and other psychosocial variables. Women were more likely to have a psychiatric diagnosis at follow-up, largely accounted for by a substantial increase in sexual dysfunction (41% of reevaluated group). None engaged in suicidal behavior or required psychiatric hospitalization during the 86.9 woman-years of observation. High-risk sexual behavior occurred after seroconversion in at least 35% of the group, with no interval decline. Most women with early stage disease were free of major psychiatric disorders at both assessments. Many developed sexual dysfunction that impaired intimate relationships and detracted from quality of life. The psychiatric natural history of HIV infection in women appears to differ from that observed in studies of men.

Psychiatric Manifestations of Voltage-Gated Potassium-Channel Complex Autoimmunity

The authors describe the neuropsychiatric spectrum of voltage-gated potassium-channel complex (VGKC) autoimmunity among 67 seropositive patients; 2 had initially been assigned a primary psychiatric diagnosis. Diverse manifestations were recorded, often affective-predominant. Symptoms for 24 patients with florid presentations included confusion, 92%; memory impairment, 75%; personality change, 58%; depression, 33%; and anxiety, 29%. Of 15 who received immunotherapy, 67% improved. Forty-three patients with milder presentations or low positive VGKC complex Ab values are also described. Neuropsychiatric presentations were significantly associated with higher autoantibody values. Improvements were most evident in patients treated early, which emphasizes the need for early diagnosis and immunotherapy initiation.

Psychiatric Characteristics of Consecutively Evaluated Outpatient Renal Transplant Candidates and Comparisons With Consultation-Liaison Inpatients

The purpose of this study was to empirically define psychiatric characteristics of renal transplantation candidates and determine whether demographic, psychiatric predisposition, psychiatric impairment, and psychiatric diagnosis characteristics differ from those of consultation-liaison (C-L) service inpatients. Standard clinical information recorded by a C-L service for 66 consecutively evaluated renal transplant candidates and 134 C-L inpatients was compared. The results revealed that the transplantation evaluation patients differ demographically from the C-L inpatients. The C-L inpatients are more likely to report past history of mental health treatment, but the two groups are equally likely to report past substance use disorder treatment. Mean scores on the Global Assessment of Functioning Scale and Hamilton Anxiety and Hamilton Depression scales are less impaired in the transplant candidates. Mini-Mental State Exam mean scores are not significantly different. Five psychiatric diagnoses are significantly more likely in the C-L inpatients; only one is more likely in the transplant candidates. The authors conclude that the psychiatric characteristics of renal transplant candidates are distinct in many respects, confirming the unique skills needed by C-L psychiatrists who do pretransplant psychiatric evaluations.

Reprint of: Psychosomatic medicine and consultation-liaison psychiatry: Scope of practice, processes, and competencies for psychiatrists working in the field of CL psychiatry or psychosomatics. A consensus statement of the European Association of Consultation-Liaison Psychiatry and Psychosomatics (EACLPP) and the Academy of Psychosomatic Medicine (APM)

OBJECTIVE In 2008, the Board of the European Association of Consultation-Liaison Psychiatry and Psychosomatics (EACLPP) and the Academy of Psychosomatic Medicine (APM) Council commissioned the creation of a task force to study consensus-based summaries of core roles, scope of clinical practice, and basic competencies for psychiatrists working in the field of Psychosomatic Medicine (PM) and/or Consultation-Liaison Psychiatry (CLP). METHOD The task force used existing statements of competencies and feedback from EACLPP and APM symposia and workshops to develop a draft document. After review by the EACLPP and APM committees, and the EACLPP Board and APM Council, a period of comment from the field preceded a final draft resubmitted for consideration of the EACLPP Board and APM Council in February 2010. RESULTS The two organizations completed approval of final publication of the consensus statement on June 11, 2010. This consensus statement is a summary of clinical competencies, scope of clinical effort, and roles considered by the sponsoring organizations to be fundamental to the practice of this subspecialty or special area of expertise, anywhere, of PM or CLP. CONCLUSION This consensus statement delineates a set of basic competencies and roles of a PM/CLP psychiatrist to serve as an internationally recognized base that may be used by national societies and institutions to formulate their own competencies, scope of practice, and roles or help with guideline formulation.

Neurosyphilis: A psychiatric perspective

Abstract The clinical picture of neurosyphilis has changed in recent years, and its manifestations may mimic virtually any psychiatric disorder, including depression, dementia, mania, psychosis, and delirium. Consequently, a high index of suspicion and routine serologic screening of psychiatric and neurologic patients are needed. Following a short survey of the medical aspects of neurosyphilis, this review of the literature examines the psychiatric manifestations and discusses the somewhat complex problem of confirming the diagnosis.

Delirium: An evidence-based medicine (EBM) monograph for psychosomatic medicine practice, comissioned by the Academy of Psychosomatic Medicine (APM) and the European Association of Consultation Liaison Psychiatry and Psychosomatics (EACLPP)

a Department of Psychiatry, Maastricht University Medical Centre, P.O. Box 5800, 6212 AZ Maastricht, The Netherlands b Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, FL, USA c Department of Psychiatry, University of California, San Francisco, CA, USA d Medical Education Programme Psychiatry, San Francisco School of Medicine, University of California (Fresno Campus) and Fresno County Department of Behavioral Health, Fresno, CA, USA e Ingham Regional Medical Center, Lansing, MI, USA f Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA g Department of Psychosomatic Medicine and Psychotherapy, General Hospital Nuremberg, Nuremberg, Germany h Oncology Supportive Care Services, Samuel Oschin Comprehensive Cancer Institute, Samuel Oschin Cancer Center, Los Angeles, CA, USA i Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

Toward defining the scope of psychosomatic medicine practice: psychosomatic medicine in an outpatient, tertiary-care practice setting.

BACKGROUND Because psychosomatic medicine (PM) is increasingly practiced in outpatient settings, the scope of practice needs to be delineated from community psychiatry and inpatient psychiatry work. OBJECTIVE The authors sought to address the question of whether outpatient activities are a definably part the scope of practice of PM. METHOD Three clinical groups were compared: 200 PM outpatients, 200 consultation-liaison (CL) inpatients, and 200 community-psychiatry (CP) outpatients. RESULTS The groups differed significantly in 49 of 112 demographic and clinical comparisons (43.8%). Analysis of individual measures validated the concept that PM outpatient practice requires traditional PM/CL expertise with medical-psychiatric differential diagnosis, unexplained physical symptoms, pain, and psychopharmacological management in medically ill and geriatric patients. CONCLUSION Outpatient PM experiences may also enhance training opportunities, given an expanded case-mix.

Psychosomatic Medicine and Consultation-Liaison Psychiatry: Scope of Practice, Processes, and Competencies for Psychiatrists or Psychosomatic Medicine Specialists A Consensus Statement of the European Association of Consultation- Liaison Psychiatry and the Academy of Psychosomatic Medicine

OBJECTIVE In 2008, the Board of the European Association of Consultation-Liaison Psychiatry and Psychosomatics (EACLPP) [corrected] and the Academy of Psychosomatic Medicine (APM) Council commissioned the creation of a task force to study consensus-based summaries of core roles, scope of clinical practice, and basic competencies for psychiatrists working in the field of Psychosomatic Medicine (PM) and/or Consultation-Liaison Psychiatry (CLP). METHOD The task force used existing statements of competencies and feedback from EACLPP and APM symposia and workshops to develop a draft document. After review by the EACLPP and APM committees, and the EACLPP Board and APM Council, a period of comment from the field preceded a final draft resubmitted for consideration of the EACLPP Board and APM Council in February 2010. RESULTS The two organizations completed approval of final publication of the consensus statement on June 11, 2010. This consensus statement is a summary of clinical competencies, scope of clinical effort, and roles considered by the sponsoring organizations to be fundamental to the practice of this subspecialty or special area of expertise, anywhere, of PM or CLP. CONCLUSION This consensus statement delineates a set of basic competencies and roles of a PM/CLP psychiatrist to serve as an internationally recognized base that may be used by national societies and institutions to formulate their own competencies, scope of practice, and roles or help with guideline formulation.

Serotonin transporter gene promotor polymorphism (5-HTTLPR) associations with number of psychotropic medication trials in a tertiary care outpatient psychiatric consultation practice.

OBJECTIVE The authors tested the hypothesis that the short allele of 5-HTTLPR is associated with number of psychotropic medication trials as a measure of treatment-resistance or intolerance in psychosomatic medicine (PM) outpatients. METHODS Review of Mayo Clinic PM outpatient 2008 records identified 44 (20.6%) who had 5-HTTLPR genotype tests. A univariate analysis screened for factors that could account for number of medication trials. Logistic regression then determined degree of association between 5-HTTLPR genotype category and number of pharmacological trials. RESULTS Univariate analysis revealed significant differences across the ordinal genotype spectrum long/long, short/long, short/short in mean number of overall psychotropic medication trials (8.9, 14.8, 18.0, P = 0.002), mean number of antidepressant trials (4.3, 7.2, 8.1, P = 0.018), mean number of mood stabilizer trials (0.8, 1.9, 2.3, P = 0.008), percent living alone (7%, 25%, 50%, P = 0.020), reported family history of depression (93%, 65%, 40%, P = 0.006), and reported family history of chemical dependency treatment (50%, 35%, 10%, P = 0.050). There were trends for differences in consultation reason for unexplained symptoms (14%, 25%, 50%, P = 0.063), and diagnoses of somatoform disorder (7%, 30%, 40%, P = 0.060), and generalized anxiety disorder (43%, 65%, 80%, P = 0.064). After controlling for other differences, presence of the short allele remained associated with number of psychotropic medication trials (OR 4.779, 95% CI 2.263-6.771, P = 0.004), and number of antidepressant trials (OR 1.591, 95% CI 1.072-2.762, P = 0.019). CONCLUSION 5-HTTLPR testing may identify PM outpatients at higher relative risk for pharmacotherapy treatment non-response or intolerance who may benefit from alternative or augmentative medication recommendations or non-pharmacological interventions.