Faculty Bibliography

BACKGROUND:Existing literature about the psychological side effects of hormonal contraception (HC) is limited. The goal of this study is to better characterize patients' subjective experiences with HC, its side effects, and contraception counseling. METHODS:This is a cross-sectional, survey-based study using a convenience sample of patients who had used HC at some point in their lives. Recruitment occurred from June 2021-February 2022. RESULTS:Of the 188 responses included in the analysis, 43.6% reported experiencing mood changes as a side effect of HC at some point in their lives. The most common reason participants cited for discontinuing or switching contraception methods was side effects (48.3%). Participants with a history of psychiatric illness were significantly more likely to report mood changes as a side effect of their HC (61.2%) compared to participants with no history of psychiatric illness (29.5%). Among patients with a history of psychiatric illness, 38.8% responded that their psychiatric symptoms worsened with HC while only 11.2% responded that their symptoms improved with HC. The majority (83%) of participants responded that their provider never mentioned the possibility of psychological side effects during contraception counseling. If/when they experienced side effects associated with their HC, 22.7% of participants disagreed that their provider adequately addressed their concerns. CONCLUSION/CONCLUSIONS:These findings suggest that mood changes may be among the most common perceived side effects of HC and speak to a disconnect between patients and providers when it comes to discussing the possibility of psychological side effects with HC.

Background: Consultation-Liaison (CL) psychiatrists frequently provide consultation for patients prescribed psychotropic medications who have complex cardiopulmonary disease, including prolonged QTc interval and risk for fatal ventricular arrhythmias, like torsades de pointes (TdP). CL Psychiatrists routinely utilize QTc measurements, along other risk factors, to inform risk-benefit analysis when recommending psychotropic medications known to prolong QTc. In order to assess the risk of certain psychotropic medications, the literature suggests relying on EKG parameters not routinely available on automated EKG interpretations. For example, in conditions where a ventricular conduction delay results in a widening of the QRS interval, different methods of correcting the QT interval are required. However, the methods most supported by the literature require complex calculations, limiting their clinical utility especially during behavioral emergencies, as there were no application based or online calculators that offer these formulas. (Funk et al, 2021) Method: Using the Calconic online interactive calculator platform, we created an online calculator that provides the CL psychiatrist with a point-of-care assessment of the QTc interval. This calculator includes the Hodges formula for correcting QTc; Hodges is thought to provide more accurate rate correction than the more commonly available Bazett formula which can overestimate QTc in tachycardic patients. (Beach et al, 2018). In addition, the calculator identifies prolonged QRS intervals and offers four methods for correction: the Bogossian formula with Hodges correction for QTc, the Rautaharju formula for QTc, corrected JT interval (JTc) and the JT prolongation index (JTi). The calculator is optimized for mobile devices, but can be accessed by any web browser (tinyurl.com/QTcCal). We present three cases derived from our clinical experiences to demonstrate the utility of the calculator. Cases: #1: Patient taking methadone and QTc -Bazett prolongation in setting of elevated heart rate. The online calculator recalculates the QTc interval using the Hodges correction supports a recommendation to continue methadone. #2: Patient on aripiprazole and QTc-Bazett prolongation in setting of widened QRS interval. The online calculator corrects for heart rate and widened QRS interval with multiple formulas, the results which support a recommendation to continue aripiprazole. #3: Acute agitation and QTc-Bazett prolongation in an elderly patient. The online calculator corrects for heart rate and widened QRS; however, with these corrections, the risk of TdP remained elevated and the clinician recommends using intravenous valproate for agitation instead of antipsychotics.
Conclusion(s): The interactive online calculator is an effective, point-of-care tool to assist CL psychiatrists in assessing the arrhythmia risk of QTc prolonging medication, including antipsychotics in medically ill patients. References: Beach SR, Celano CM, Sugrue AM, et al. QT Prolongation, Torsades de Pointes, and Psychotropic Medications: A 5-Year Update. Psychosomatics. 2018;59(2):105-122. Funk MC, Beach SR, Bostwick JR, et al. QTc Prolongation and Psychotropic Medications. Am J Psychiatry. 2020;177(3):273-274.
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Background/Significance: Catatonia is common in anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis (Espinola-Nadurille, 2019). The glutamate NMDAR antagonists amantadine and memantine are effective in catatonia (Beach, 2017), but data on their use in anti-NMDAR encephalitis is limited. We describe three patients with catatonia due to anti-NMDAR encephalitis treated with NMDAR antagonists and propose a possible mechanism underlying differential outcomes. Case 1: A 20-year-old woman presented with catatonic symptoms after successful treatment of anti-NMDAR encephalitis with immunotherapy and salpingo-oopherectomy for ovarian teratoma. Initial Bush-Francis Catatonia Rating Scale (BFCRS) score was 22. Lorazepam 2.5 mg three times daily was partially effective, but increased doses caused sedation. Memantine was titrated to 10 mg twice daily with complete resolution of catatonia over two weeks. Case 2: A 26-year-old woman presented with catatonic with BFCRS score of 25, after successful immunotherapy for anti-NMDAR encephalitis. Lorazepam 2 mg four times daily was partially effective, but further increase caused respiratory depression. Memantine 10 mg daily resulted in further improvement. Lorazepam titration to 4 mg four times daily was then possible, with complete resolution of catatonia over two weeks. Case 3: A 31-year-old woman with anti-NMDAR encephalitis presented with catatonic symptoms with BFCRS score of 22, after a hospital course significant for limited response to immunotherapy with persistently elevated serum anti-NMDAR antibody titers. Lorazepam 2 mg three times daily was partially effective, but further increase caused sedation. Both amantadine 100 mg twice daily and memantine 10 mg were trialed but were discontinued due to agitation. Mutism and negativism persisted, with a discharge BFCRS score of 12.
Discussion(s): Memantine was effective for catatonia and well tolerated in two patients with successfully treated anti-NMDAR encephalitis, but both amantadine and memantine caused agitation in a third patient with active disease. NMDARs are reversibly internalized in the presence of anti-NMDAR antibodies, leading to a compensatory increase in downstream glutamatergic tone. We hypothesize that NMDAR reemergence after successful treatment, in the context of excess extracellular glutamate, creates a state of excitotoxicity contributing to catatonic signs for which NMDAR blockade can be effective. In the third case, where NMDARs presumably remained internalized in the presence of persistent anti-NMDAR antibodies and a state of NMDAR hypofunction persisted, further NMDAR blockade caused clinical worsening. Conclusion/Implications: NMDAR antagonists can be safe and effective in patients with residual catatonia following successful treatment of anti-NMDAR encephalitis but may be less useful during active disease. More work is needed to clarify best practices for patients with catatonia due to anti-NMDAR encephalitis. References: 1. Espinola-Nadurille M, Flores-Rivera J, Rivas-Alonso V, et al. Catatonia in patients with anti-NMDA receptor encephalitis. Psychiatry Clin Neurosci. 2019;73(9):574-580. 2. Beach SR, Gomez-Bernal F, Huffman JC, Fricchione GL. Alternative treatment strategies for catatonia: A systematic review. Gen Hosp Psychiatry. 2017;48(June):1-19.
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Background: Rates of alcohol use disorder amongst women have increased markedly since the start of the Covid-19 Pandemic with some studies showing as much as a 41% increase in heavy drinking days (1). Among women with alcohol use disorder, there is a high degree of comorbidity with eating disorders (ED) with studies suggesting rates of co-occurring disease as high as 23-50%(2). However, there is little data on the assessment of transplant recipients presenting with co-occuring ED and AUD. Case: A 34-year-old woman with no known past psychiatric or substance use history presented to our hospital in acute hepatic failure (MELD Score 34) in the context of escalating alcohol use over the course of the COVID-19 Pandemic. As the patient did not respond to multiple medical therapies, evaluation for liver transplantation was initiated. The patient was assessed using the Stanford Integrated Psychosocial Assessment for Transplant (SIPAT), and found to be a high risk candidate. During the course of our evaluation, the patient demonstrated a lack of interest in eating food, refusing to eat food that required chewing, and expressed multiple consequences about the aversive consequences of eating. She described extremely restrictive eating patterns with her lowest weight being 95 lbs (BMI < 16), leading to nutritional deficiencies, peripheral neuropathy and anemia. Given the absence of excessive concern regarding appearance or body weight, a diagnosis of avoidant restrictive food intake disorder (ARFID) was made. Despite efforts to engage the patient, she demonstrated little understanding of her ED. The patient was declined for listing and medically stabilized. She was declined by all inpatient substance use programs given the extent of her ED and rejected recommendations for targeted ED treatment. She was ultimately discharged to an intensive outpatient program for AUD.
Discussion(s): There is a paucity of information regarding liver transplantation in patients with co-occurring AUD and EDs. However, there are many unique considerations in the management of this patient population in both the pre- and post- transplant period. Existing screening methods such as the SIPAT do little to evaluate transplant risk in patients with EDs relative to other psychiatric illnesses. And while predictive risk factors for recurrence of alcohol use after transplant have been identified, little is known about the risk factors for ED relapse. It appears that the emphasis on abstinence from alcohol in the post-transplant period can be a potent trigger for ED relapse(3). Post-transplant, patients with ED have an increased risk of relapse to alcohol and poorer retention in residential treatment(4).
Conclusion(s): Patients with co-occurring ED and AUD requiring liver transplantation are a challenging patient population with complex pre- and post-transplant considerations. References: 1. Pollard M, et al. "Changes in Adult Alcohol Use and Consequences During COVID-19 Pandemic in the US." JAMA Netw Open. 2020;3(9). 2. Bulik, Cynthia, et al. "Alcohol Use Disorder Comorbidity in Eating Disorders: A Multi-center Study." Journal of Clinical Psychiatry. 65:7, July 2004. 3. Coffman K L, et al. Treatment of the Postoperative Alcoholic Liver Transplant Recipient With Other Addictions." Liver Transpl Surg. 1997;3:322-327. 4. Elmquist, J. et al., "Eating Disorder Symptoms and Length of Stay in Residential Treatment for Substance Use: A Brief Report." Journal of Dual Diagnosis, 11(3-4), 233-237. https://doi.org/10.1080/15504263.2015.1104480.2015.
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Background: CL psychiatrists are uniquely positioned to combat structural racism in medicine Currently, there are no published papers examining racial bias in the management of psychiatric emergencies in the general medical hospital. Given the potential for restrictive clinical interventions that directly challenge a patient's autonomy (including intramuscular injections and restraints), our group embarked on a long-term, quality improvement project to detect and address racial bias affecting the clinical management of these psychiatric emergencies.
Method(s): Our institution has a multidisciplinary behavioral code team known as the Behavioral Emergency Response Team (BERT) that responds to behavioral emergencies throughout the medical hospital. Secondary BERT event data occurring from 2017 to 2020 was combined with demographic data from the electronic medical record. Race and ethnic data were collapsed into unique, phenotypic categories. BERT events were coded based on the most restrictive intervention utilized. Descriptive statistics were used to describe the sample and examine whether race / ethnicity correlated with BERT intervention utilized, diagnostic impression, reason for BERT activation, or recurrent BERTs.
Result(s): Our sample included 1532 BERT events representing N = 902 unique patients. The main interaction of BERT intervention by Race / Ethnic category reached statistical significance (p=0.04). Though most BERTs only required verbal de-escalation (n=419, 46.45%), 3% of BERTs (n = 29) escalated to 4-pt restraints (most restrictive intervention). Though reaching level 5 was rare, Black patients had a statistically significant higher likelihood of receiving this intervention compared with White patients (6% v 2%, p=0.027) and compared with all other non-Black patients (6% v 2%, p=0.040). Although the overall comparison for Race/Ethnicity and the diagnostic impression "Psychosis" did not reach significance (p=0.086), targeted analysis showed that Black patients were significantly more likely to have "Psychosis" listed as a contributing factor compared with White patients (p=0.009) and all other non-Black patients (p=0.016). Several other comparisons with Race / Ethnic category reached statistical significance: Age (p=0.048), and need for interpreter yes/no (p<0.001). Closer examination of the interaction of Race/Ethnicity x Need for Interpreter revealed that half of events involving Asian patients (n=22, 53.66%) and a third of events involving Hispanic patients (n=29, 30.53%) required interpreter services.
Discussion(s): This study demonstrates the feasibility of investigating racial bias in behavioral emergency management. The results of this preliminary analysis suggest multiple areas for enhanced education, self-awareness development, and programmatic improvement to target systemic racism, decrease racial bias, and improve patient care. These areas include bias in restraints use, the role of language in behavioral emergencies, and the influence of race on perception of underlying diagnosis.
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