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Adjunctive Memantine for Catatonia Due to Anti-NMDA Receptor Encephalitis

Kim, Katherine; Caravella, Rachel; Deutch, Allison; Gurin, Lindsey
PMID: 37415500
ISSN: 1545-7222
CID: 5539392

Psychiatric Consultation When a Patient Refuses Medical Care

Caravella, Rachel A.; Skimming, Kathryn; Bradley, Mark V.
Psychiatry consultants are often called on by colleagues to assess a pa-tient"™s capacity to refuse medical care. These situations can expand beyond the boundaries of a decision-making capacity question to become clinically, legally, ethically, and emotionally com-plex situations. This article provides a framework for psychiatrists to navigate these complexities when asked to eval-uate a patient for the capacity to refuse medical care. We review decision-mak-ing capacity as an element of informed consent in order to clarify the psychia-trist"™s role in these consults. We dis-cuss related ethical and legal questions that can arise when a patient refuses treatment. This article also addresses other skills beyond decision-making capacity assessment that psychiatrists may utilize to support nonpsychiatrist colleagues and advance the care of the hospitalized patient.
ISSN: 0048-5713
CID: 5424442

Psychiatric Considerations in Perinatal Mental Illness

Azarchi, Sarah; Ackerman, Marra; Caravella, Rachel; Jones, Clancy; Kondas, Cathy; Madanes, Sharon; Rehim, Aimy; Deutch, Allison
ISSN: 0048-5713
CID: 5525362

(4) Creation of a Mobile-based Application to Assess Risk of Psychiatric Medications in the Setting of Prolonged QTc Interval [Meeting Abstract]

Ying, P; Deutch, A B; Sidelnik, S A; Abroms, M; Caravella, R A
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 ( 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.
ISSN: 2667-2960
CID: 5511772

(175) Creating Operational and Safety Metrics for a Consultation-Liaison (C-L) Psychiatry Service [Meeting Abstract]

Ying, P; CARAVELLA, R A; Ackerman, M G; Ginsberg, D L; Sreedhar, A; Casale, J A
Background: Data that demonstrates productivity, value or quality in clinical practice are high priority in healthcare systems but are less developed for the field of C-L Psychiatry. Recent work has focused on qualitative metrics (Kovacs et al., 2021) and service effectiveness (Wood, et al., 2014) but there is no consensus on what operational or safety metrics CL teams should track. Without reliable metrics, it can be challenging to illustrate daily CL service operations or provide quantitative support to justify expansion of staffing to hospital leadership. In response to an administrative need, our service started an ongoing collaboration with departmental leadership, administrative support staff, and medical center information technology to develop CL operational and safety metrics.
Method(s): We developed 17 monthly and 9 daily metrics to describe our operations. These metrics cluster into the following groups: clinical volume and encounters; behavioral emergency response activations (BERTs) and bedside safety huddles for patients with recent violence; length of stay; proactive Addiction CL service; behavioral acuity highlights (ex: 1:1s for suicide risk); and "CL Dwell Time" which is the time from medical clearance to discharge to inpatient psychiatry (if applicable). From this data, we selected key metrics to display on a quarterly basis to senior hospital leadership in the form of a "metrics card" to parallel our medicine and surgical colleagues who present High Reliability Organization score cards.
Result(s): Our service demonstrated increases in consultation requests, completed consultations, total clinical encounters and activation of BERTs. We compared trends for total length of stay by ultimate discharge destination, such as psychiatric admission vs acute rehabilitation vs home. The data allowed for deeper dives into concerning trends, such as the problem of escalating violence in the general medical hospital as evidenced by the increasing BERTs per month over several years. We examined the number of unique patients with BERTs, BERTs per patient, BERTs per patient by psychiatric diagnoses, and BERT total per medical unit or service. The data has allowed for the development of interventions to reduce BERTs for specific populations and medical units.
Discussion(s): The creation of comprehensive CL service operational metrics has provided our team with the ability to analyze clinical, acuity, and safety trends over the past 2 years. This ability has led to improved advocacy for service needs (i.e. expansion of FTE and fellowship lines), data-informed communication with hospital leadership, and identification of clinical care gaps needing quality improvement. References: 1. Kovacs Z, Asztalos M, et al. Quality assessment of a consultation-liaison psychiatry service. BMC Psychiatry. 2021 Jun 1;21(1):281. 2. Wood R, Wand AP. The effectiveness of consultation-liaison psychiatry in the general hospital setting: a systematic review. J Psychosom Res. 2014 Mar;76(3):175-92.
ISSN: 2667-2960
CID: 5511782

(46) Examining Racial Bias in the Use of Restraints During Behavioral Emergencies [Meeting Abstract]

Arbit, D; Askalsky, P; Ying, P; Caravella, R A
Background: Recent papers have argued that establishing a Behavioral Emergency Response Team (BERT) in the general medical setting can lead to more equitable care for patients (Parker et al., 2020). An unpublished study by our own service on BERT outcomes found that restraints were used to deescalate 3% of patients (n = 29). Of those included in the study sample, Black patients were overrepresented. This was also a pattern in a 2021 study of Emergency Department visits (Wong et al, 2021). The purpose of this planned study is to examine possible racial, ethnic, gender, or language bias patterns in the use of 4-point restraints for behavioral control in the general medical setting when the BERT was activated versus during usual care (no BERT). We intend to use the data to find actionable targets for programmatic and / or institutional quality improvements.
Method(s): This IRB approved study will utilize secondary analysis of an existing clinical dataset combined with retrospective chart review. We will examine all episodes of 4-point restraint use occurring in adult inpatients admitted to any medical or surgical unit from Feb 2017 - December 2021. The following variables will be collected: demographics (race, ethnicity, gender, language, age, height & weight), restraint use (indication, duration), and BERT / psychiatric variables (Psychiatry CL consulted Y/N, BERT involved Y/N, diagnosis). The new combined dataset will be analyzed using simple descriptive statistics. The pattern of restraint use in two subgroups (BERT involved versus BERT not involved) will be compared to investigate whether or not involvement of the BERT influences bias.
Result(s): Our study has been IRB approved. Fifty-seven unique patients have been identified for study inclusion, including 29 patients with restraints documented during a BERT activation and 28 patients with restraints without BERT activation. Preliminary chart review shows variability in documentation on events of restraint use. Data collection is ongoing.
Discussion(s): Preliminary data suggests there may be an important opportunity to improve clinical care by standardizing ordering requirements and documentation of restraint use. Given the ongoing harm that racism poses for both patients and staff, understanding how it influences restraint utilization and BERT activation will guide local programmatic and institutional change, and may help inform future research into bias in mental health care. This project is part of a long-term quality improvement project to examine racial bias in the management of behavioral emergencies throughout our hospital. References: Parker CB, Calhoun A, Wong AH, Davidson L, Dike C. A Call for Behavioral Emergency Response Teams in Inpatient Hospital Settings. AMA J Ethics. Nov 1 2020;22(11):E956-964. Wong AH, Whitfill T, Ohuabunwa EC, et al. Association of Race/Ethnicity and Other Demographic Characteristics With Use of Physical Restraints in the Emergency Department. JAMA Netw Open. 2021;4(1):e2035241.
ISSN: 2667-2960
CID: 5511792

Glutamate Antagonists in Catatonia Due to Anti-NMDA Receptor Encephalitis [Meeting Abstract]

Kim, K; Caravella, R A; Deutch, A; Gurin, L
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.
ISSN: 2667-2960
CID: 5291752

#BlackLivesMatter to C-L Psychiatrists: Examining Racial Bias in Clinical Management of Behavioral Emergencies in the Inpatient Medical Setting [Meeting Abstract]

Caravella, R A; Ying, P; Ackerman, M; Deutch, A; Siegel, C; Lin, Z; Vaughn, R; Madanes, S; Caroff, A; Storto, M; Polychroniou, P; Lewis, C; Kozikowski, A
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.
ISSN: 2667-2960
CID: 5291782

Report of the Academy of Consultation-Liaison Psychiatry Task Force on Lessons Learned From the COVID-19 Pandemic: Executive Summary

Shapiro, Peter A; Brahmbhatt, Khyati; Caravella, Rachel; Erickson, Jennifer; Everly, George; Giles, Karen; Gopalan, Priya; Greenspan, Heather; Huijón, R Michael; Key, R Garrett; Kroll, David; Prince, Elizabeth; Rabinowitz, Terry; Saad-Pendergrass, Dahlia; Shalev, Daniel
BACKGROUND:The COVID-19 pandemic forced consultation-liaison psychiatrists to adapt to unprecedented circumstances. The Academy of Consultation-Liaison Psychiatry (ACLP) recognized the need and opportunity to assess its response and convened a task force in mid-2020 to review the lessons learned from the initial experience of the COVID-19 pandemic. OBJECTIVE:The aim of the study was to summarize experience and make recommendations to the ACLP Board of Directors about potential ACLP directions related to current and future pandemic response. METHODS:In August-November 2020, the task force reviewed local experiences, ACLP list-serv contributions, and the published literature and generated recommendations for ACLP actions. RESULTS:Recommendations addressed telepsychiatry, hospital staff wellness, support for consultation-liaison psychiatrists, the need for additional research on psychiatric and neuropsychiatric aspects of COVID-19, and the ACLP's role in advocacy and dissemination of information. The task force report was submitted to the ACLP Board of Directors in November 2020. CONCLUSIONS:As the preeminent organization of consultation-liaison psychiatrists, the ACLP can implement actions related to pandemic awareness and preparedness for the benefit of consultation-liaison psychiatrists, other health care workers, patients, and the general population.
PMID: 34000470
ISSN: 2667-2960
CID: 4936512

Successful Use of Electroconvulsive Therapy for Catatonia After Hypoxic-Ischemic Brain Injury [Case Report]

Kim, Katherine; Anbarasan, Deepti; Caravella, Rachel A; Nally, Emma; Ying, Patrick; Gurin, Lindsey
PMID: 33023757
ISSN: 2667-2960
CID: 5442492