From the Editor
In my last hospital job, an afternoon might involve seeing a gentleman with poorly controlled diabetes, a woman who wasn’t participating in her post-hip physiotherapy, and an ICU patient with multiple problems. The common thread: they all had psychiatric diagnoses (PTSD, depression, and delirium, respectively).
Patients with physical and mental health problems can be costly and complicated. They also pose a challenge for a health care system that is designed for the simplicity of tackling one problem at a time.
This week, we look at a couple of papers on this interface between mental and physical health.
In the first paper, the University of Rochester’s Mark A. Oldman and his co-authors wonder if proactive psychiatric consultations can reduce hospital length of stay. With a systematic review, they conclude: “Our review indicates that proactive models of CL psychiatry whose screening is enriched by clinical expertise in mental health care and that deliver enhanced, proactive mental health services appear to reduce LOS, with preliminary cost-benefit analyses reporting favorable returns on investment that more than offset the increased costs of providing this level of enhanced care.”
Good Hospital, Good CL Service?
In the second paper, the University of Toronto’s Matthew J. Burke, a neurologist, considers patients who present with symptoms unexplained by medical disease. “The irony of ‘it’s all in your head’ is that although this phrase is often used inappropriately and dismissively, it is technically correct.”
“A systematic review of proactive psychiatric consultation on hospital length of stay”
Mark A. Oldham, Khushminder Chahal, Hochang B. Lee
General Hospital Psychiatry, September-October 2019
More than a third of medical and surgical inpatients have psychiatric comorbidity, and up to half of inpatients have a clinically-actionable mental health issue. However, literature suggests that more than half of hospital patients with psychiatric comorbidity are not recognized by primary teams with the lowest rates of detection for chronic psychiatric illness, such as anxiety disorders or personality disorders. The unmet need for psychiatric care in the general hospital is substantial and compromises the quality and delivery of care.
Such psychiatric comorbidity is known to predict longer hospital length of stay (LOS). Roughly three decades ago Ackerman et al. found that patients receiving psychiatric consultation had 2.5-times the LOS relative to a comparison group. This same research team also demonstrated a strong correlation between the timing of psychiatric consultation and hospital LOS with earlier consultations associated with a shorter LOS. Subsequent studies have consistently confirmed this relationship between time to consultation and LOS, which persists even after adjusting for severity of medical illness. Whereas these findings were based on observational studies, the research question emerged: might CL psychiatry reduce hospital LOS and improve outcomes if it met mental health needs among general hospital patients sooner?
Mark A. Oldham
So begins a paper by Dr. Oldham and his co-authors.
Here’s what they did:
- They conducted a systematic review drawing on major databases (including Pubmed and PsychINFO), up to May 2019.
- Search terms included “length” and “proactive.”
- A review of abstracts and titles narrowed the search.
- They focused on “proactive models” – that is, “proactive services included here not only aim to identify patients who may benefit from timely mental health care but also provide care proactively. Specifically, models that take a team-based approach by embedding mental health providers into medical teams and the medical milieu broadly report reduction in LOS.”
Here’s what they found:
- They found 12 studies, and added a study in press.
- The studies were overwhelmingly from the United States.
- In terms of demographics: “The mean age of patients across studies ranged considerably from 47.6 to 82.8 yrs. and proportion of males in a given study sample from 20.1% to 63%.”
- “Many of these studies report reduced LOS, but the heterogeneity across study designs makes it difficult to attribute this to any one study element in isolation.”
Our review indicates that proactive models of CL… appear to reduce LOS, with preliminary cost-benefit analyses reporting favorable returns on investment that more than offset the increased costs of providing this level of enhanced care…
A few thoughts:
- This is a good paper.
- In a world of tight budgets, it’s good to see a health service evaluated in terms of a clear metric (length of stay) – with obvious cost-benefit implications.
- Most studies analyzed by the authors showed a reduction in the length of stay of patients.
- That said, this paper drew from many studies with very different parameters, including a study that only considered those 75 years of age and older, and another that excluded those with cognitive impairment. Some of the studies were published many years ago (four of the studies were published more than 20 years ago) when inpatient care was markedly different.
- Did any of these studies do a randomization between CL care and treatment as usual? Two did, with neither finding a reduction in length of stay. (!)
- Though the authors looked to include team-based care, the actual teams varied greatly, from a nurse supervised by a psychiatrist to full, multidisciplinary teams. The authors argue that three elements are found in positive outcomes: “screening that draws upon mental health care expertise, integrated care delivery, and unit- or service-level analysis.”
“‘It’s All in Your Head’ – Medicine’s Silent Epidemic”
Matthew J. Burke
JAMA Neurology, 16 September 2019 Online First
‘It’s all in your head’ is a phrase sometimes said by physicians to patients presenting with symptoms unexplained by medical disease. As a neurologist specializing in neuropsychiatry, nothing bothers me more than overhearing medical colleagues proclaim this one-liner at the bedside or snicker about these patients during rounds. Unbeknownst to them, I also hear my patients’ version of being on the other end of this phrase and find myself constantly trying to repair the damage that these words can cause. Whether physicians like to admit it or not, medically unexplained symptoms encompass a vast terrain of clinical practice. In neurology, these symptoms fall under functional neurological disorder, but every specialty has their own variants and favored terminologies (eg, chronic fatigue syndrome, fibromyalgia). The inadequate management of this segment of medicine represents a silent epidemic that is slowly eroding patient-physician relationships, perpetuating unnecessary disability, and straining health care resources.
The irony of ‘it’s all in your head’ is that although this phrase is often used inappropriately and dismissively, it is technically correct. The problem does indeed lie within the head. More specifically, it lies within the brain and its complex networks that we are just beginning to understand.
Matthew J. Burke
So begins a paper by Dr. Burke.
He notes that many in neurology and psychiatry have struggled with these presentations. Dr. Jean-Martin Charcot, the 19th century neurologist, had believed that – at some point in the future – a lesion could be found with powerful microscopes.
Well, our microscopes are getting better, and we are now starting to see evidence of the predicted functional or software disruptions in the brain. We still do not fully understand what causes these software problems; however, recent research suggests a multifactorial etiology, including genetic predisposition, environmental risk factors (eg, childhood adverse events), and psychological stressors.
He closes with a call to action:
To address the epidemic itself, we desperately need more clinicians and researchers dedicated to interrogating the complex interfaces of mind, brain, and health. Currently, there are small pockets in different specialties, but these are not nearly commensurate with the volume and impact of these disorders. Second, and arguably more importantly, we need to fundamentally change the culture within the medical community to eliminate the negative connotations associated with these disorders.
A few thoughts:
- This is a good paper.
- It’s nice to see consideration of this topic in a neurology journal.
- Dr. Burke makes good points. His opening comment – about the stigma – is particularly well phrased.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.