Priya Gopalan

Guidelines for preventing common medical complications of catatonia: case report and literature review.

OBJECTIVE Comprehensive hospital-based care for individuals with catatonia relies on preventive approaches to reduce medical morbidity and mortality. Without syndrome-specific guidelines, psychiatrists must draw from measures used for general medical and surgical inpatients. We employ a prototypical case to highlight medical complications of catatonia and review preventive guidelines for implementation in the inpatient setting. DATA SOURCES Searches of the PubMed and Ovid databases were conducted from September-November 2013 using keywords relevant to 4 medical complications of catatonia: deep vein thrombosis/pulmonary embolism, pressure ulcers, muscle contractures, and nutritional deficiencies. A complementary general web-browser search was performed to help ensure that unpublished guidelines were considered. STUDY SELECTION A search for deep vein thrombosis/pulmonary embolism guidelines yielded 478 articles that were appraised for relevance, and 6 were chosen for review; the pressure ulcer guideline search yielded 5,665 articles, and 5 were chosen; the muscle contractures guideline search yielded 1,481 articles, and 3 were chosen; and the nutritional deficiencies guideline search yielded 16,937 articles, and 4 were chosen. DATA EXTRACTION Guidelines were reviewed for content and summarized in a manner relevant to the audience. No quantitative analyses were conducted. RESULTS Guidelines for deep vein thrombosis/pulmonary embolism prophylaxis support use of anticoagulant therapies for patients with catatonia who are at lower risk for acute bleeding. Pressure ulcer prevention hinges on frequent skin evaluation, use of support surfaces, and repositioning. Muscle contracture data are less clear and must be extrapolated from studies of patients with neurologic injuries. Early initiation of enteral nutrition should be considered in patients with prolonged immobility. CONCLUSIONS As medical complications are common with catatonia, implementation of preventive measures is imperative.

Blunted HPA axis activity prior to suicide attempt and increased inflammation in attempters

BACKGROUND Hypothalamic-Pituitary-Adrenal (HPA) axis dysregulation is associated with increased risk for suicidal behavior. However, it is not clear whether such dysregulation exists prior to or is a consequence of attempt. Studies also show an activation of inflammatory responses in suicidal behavior but often combine attempters with those with ideation. METHODS The sample consisted of psychiatric inpatients, aged 15-30 years, admitted for suicide attempt (SA, n=38), inpatients admitted for suicidal ideation with no prior history of attempts (SI, n=40), and healthy controls (n=37). We compared SA, SI, and controls on hair cortisol concentrations (HCC), which provides retrospective levels of cortisol and thus prior to the attempt in SA. We also compared them on the expression of genes in the HPA axis and inflammatory pathways previously implicated in suicidal behavior (GR or NR3C1, SKA2, FKBP5, IL-1β, TNF-α); plasma C-Reactive Protein (CRP); and cellular measures of glucocorticoid receptor (GR) sensitivity and stimulated production of IL-6. RESULTS We found lower HCC [β=-0.55, 95% CI (-0.96, -0.13), p=0.01, ES=-0.54] in first-time SA compared to SI and controls. In addition, SA showed lower GR or NR3C1 (α isoform) mRNA [β=-5.11, 95% CI (-10.9, 0.73), p=0.09, ES=-0.46], higher CRP [β=0.94, 95% CI (-0.004, 1.9), p=0.05, ES=0.60], and higher TNF-α mRNA [β=26.4, 95% CI (7.7, 45.2), p=0.006, ES=0.73]. CONCLUSIONS This is the first study to differentiate youth who attempt suicide from those with suicidal ideation on HCC and to show that low HCC precedes suicide attempt. Suicide attempters also showed a distinct biological profile on several markers in both the HPA axis and inflammatory pathways. Future longitudinal studies are needed to examine the ability of these biomarkers to predict suicidal behavior.

Guidelines for the Management of Pregnant Women With Substance Use Disorders

BACKGROUND Women of reproductive potential with substance use disorders, especially those who are pregnant, present many clinical challenges to healthcare providers, including comorbid psychiatric disorders, a history of trauma and abuse, avoidance of or poor access to prenatal care, fear of legal consequences, and countertransference reactions. METHODS In November 2013, members of the Womens Mental Health Special Interest Group of the Academy of Psychosomatic Medicine presented a Workshop reviewing substance abuse in pregnancy, highlighting the specific contributions that psychosomatic medicine specialists can make in the care of these patients. The discussion focused on epidemiology; maternal and fetal risks; and screening and treatment considerations for tobacco, alcohol, cannabis, opioids, benzodiazepines, stimulants, and several other substances. OBJECTIVE Our purpose in publishing this review is to provide clinicians and educators with the most up-to-date summary in this field to better engage these patients in care and break the intergenerational cycle of abuse and addiction.

Medical management of patients on clozapine: A guide for internists.

Clozapine was approved by the US Food and Drug Administration in 1989 for the management of treatment-resistant schizophrenia, and has since proven to reduce symptom burden and suicide risk, increase quality of life, and reduce substance use in individuals with psychotic disorders. Nevertheless, clozapines psychiatric benefits have been matched by its adverse effect profile. Because they are likely to encounter medical complications of clozapine during admissions or consultations for other services, hospitalists are compelled to maintain an appreciation for these iatrogenic conditions. The authors outline common (eg, constipation, sialorrhea, weight gain) and serious (eg, agranulocytosis, seizures, myocarditis) medical complications of clozapine treatment, with internist-targeted recommendations for management, including indications for clozapine discontinuation.

Prototypes of Catatonia: Diagnostic and Therapeutic Challenges in the General Hospital

Where psychiatric diagnosis is dominated by subjective report, psychosomatic medicine fosters unique opportunities for clinical assessment that is rooted firmly in the physical examination. Catatonia presents a prime example. By rendering patients unable to describe their internal experiences, catatonia demands from psychiatrists a confident comfort with its variable presentations and diagnostic challenges. This proves especially true in the general hospital. Despite a common tendency to confine the syndrome to psychiatric disease, catatonia is precipitated by general medical conditions in up to 25% of cases and can, itself, trigger serious physical complications. As a result, consultation psychiatrists find themselves routinely at the forefront in providing care for the catatonic patient. Psychiatric evaluation starts with the instinctive appraisal of a patient’s mental status, with a focus on appearance, behavior, and cognition. Often reflexively, the clinician weighs this assessment against a figurative database of characteristic disease states, or prototypes. Mental prototypes can, thereby, guide the formulation of a differential diagnosis. An emphasis on prototype models in psychiatry can be traced to Carl Jung, whose archetypes provided a theoretical framework for human behavior, perception, and cognition. Among more recent literature in psychosomatic medicine, Kahana’s and Bibring’s descriptions of personality types and Groves’ depiction of the “hateful patient” exemplify the design of memorable prototypes to help clinicians identify personality styles and associated experiences of counter-transference in the general medical setting. Prototype models have since been proposed for the diagnosis of several psychiatric conditions, including bipolar disorder and personality disorders, and to predict trends in medication adherence among patients with schizophrenia. Advocates for the use of prototypes in psychiatric nosology argue their effectiveness, pragma-

Postpartum Depression Screening: A Review for Psychiatrists.

Learning ObjectivesAfter participating in this activity, learners should be better able to:• Evaluate the rationale for screening women for postpartum depression• Assess tools for screening for postpartum depression ObjectiveTo perform a qualitative literature review on screening for postpartum depression (PPD), as applicable to the general psychiatrist. Results are classified by instrument, timing, and clinical setting of the screen. Data sourcesA literature search was conducted using the PubMed database for English-language articles published since January 1987. Of the 2406 citations initially identified, 61 articles remained after application of inclusion and exclusion criteria. ResultsAmong numerous screening tools for PPD, the Edinburgh Postnatal Depression Scale is the most widely used. Data suggest that screening for PPD should commence soon after delivery, with subsequent screens at multiple time-points in the postpartum period. Primary care, pediatric, and obstetric settings are all viable locations for screening, but are ineffective without follow-up mental health evaluations. Less data are available to define optimal patterns either for screening in psychiatric settings or for the psychiatrist’s role in managing perinatal depression. ConclusionsThe American Congress of Obstetricians and Gynecologists, American Academy of Pediatrics, and most authors firmly recommend screening for PPD. The Edinburgh Postnatal Depression Scale can be administered in various clinical settings. Screening should occur at multiple time-points throughout the first postpartum year. The psychiatrists role in early detection and prevention of PPD requires further exploration.

Assessing Career Outcomes of a Resident Academic Administrator, Clinician Educator Track: A Seven-Year Follow-up

ObjectiveThis study reports the academic outcomes, including scholarly productivity, of the graduates of one residency training track for future clinician educators and academic administrators. Since its implementation in 2008, the Academic Administrator, Clinician Educator (AACE) track at Western Psychiatric Institute and Clinic - UPMC has grown in popularity with reports of participants achieving post-graduate academic success; however, there has been no prior assessment of outcomes.MethodsIn 2015 all graduates of the track were surveyed using an anonymous, web-based survey. Twenty-nine total graduates were surveyedResultsTwenty-four graduates responded to the survey (83% response rate). The graduates are very active in academic psychiatry with 23 (96%) holding an academic appointment with different administrative roles, medical director (50%) and training director (17%) being the most frequent. Participants have also been active in pursuing scholarship with 80% presenting their scholarly projects at local and national conferences and producing post-graduate, peer-reviewed articles (50%).ConclusionThis study underscores the benefits of a clinician educator track and suggests areas for future growth.

Self-Enucleation and Severe Ocular Injury in the Psychiatric Setting

BACKGROUND Although the first medically-reported case of auto-enucleation was described in the mid-19th century, ocular self-gouging has long been depicted in historical legend and mythology. Cases of enucleation have since been identified across various cultures. Though relatively uncommon, this major form of self-mutilation now afflicts approximately 500 individuals per year, and may present more commonly among certain clinical populations. METHODS We present 2 cases of self-enucleation in patients with psychotic illnesses and review existing literature on the history of enucleation, associated pathology, and management (both medically and psychiatrically) for this serious form of self-injury. RESULTS Literature review includes a brief historical perspective of auto-enucleation and its context in psychosomatic medicine, with cases to highlight key aspects in the prevention and management of ocular self-injury. Normal eye pathology is described briefly, with a focus on medical care after self-inflicted damage, as pertinent to consultation psychiatrists. Interventions for behavioral and pharmacologic management of agitation and impulsivity are reviewed, including consideration for electroconvulsive therapy, in this particular context. CONCLUSION Although severe ocular self-injury is uncommon, psychiatrists should be familiar with approaches to prevent and manage auto-enucleation in individuals at risk thereof. Consultation psychiatrists must work closely with ophthalmologists to address affective, behavioral, and cognitive triggers and complications of ocular self-injury.

Physical Examination for the Academic Psychiatrist: Primer and Common Clinical Scenarios

As clinical psychiatry has evolved to mirror the patient care model followed in other medical specialties, psychiatrists are called upon increasingly to utilize general medical skills in routine practice. Psychiatrists who practice in academic settings are often required to generate broad differential diagnoses that include medical and neurologic conditions and, as a result, benefit from incorporating physical examination into their psychiatric assessments. Physical examination allows psychiatrists to follow and to teach patient-informed clinical practices and comprehensive treatment approaches. In this commentary, the authors encourage routine use of a targeted physical examination and outline common scenarios in which physical examination would be useful for the academic psychiatrist: delirium, toxidromes, and unexplained medical conditions (e.g., somatic symptom disorders).

Capacity evaluations in late-stage pregnancy.

Consultation psychiatrists are often called upon to assess capacity for medical decision-making in the obstetrical setting. Although these assessments are similar to those in other clinical settings, there is one notable difference: the presence of a fetus who can suffer adverse outcomes due to decisions of the pregnant patient, particularly refusal of medical treatment. Specific questions of capacity vary with the stage of pregnancy. Evaluations in the first trimester (weeks 1–12) are often related to requests for elective termination, second trimester (weeks 13–28) assessments tend to focus onmanagement of nonviable pregnancies, including termination and delivery induction, and capacity evaluations in the third trimester (weeks 29–40) often center on consent for emergent or elective cesarean section. Assessments of medical decision-making capacity in the obstetrical setting have unique ethical and legal implications, both for the pregnant patient and for her treating physician. Questions of capacity during pregnancy are perhaps best approached using a framework that considers the ethically-based obligations that a pregnant woman potentially has toward her unborn child, the treatingphysician’s obligations to bothmother and child, and the conflicts that arise when these obligations go unfulfilled. In support of this, we present 2 obstetrical cases that involve questions of capacity during the third trimester of pregnancy, followed by a discussion of relevant bioethical and legal issues as well as recommendations for the consultation psychiatrist.