The Prevalence of Psychiatric Disorders in General Hospital Inpatients: A Systematic Umbrella Review

Aggressive Behaviour Risk Assessment Tool for Hospitalised Patients in Non-Psychiatric Inpatient Units

AIM

To refine and validate an electronic version of the Aggressive Behaviour Risk Assessment Tool (ABRAT) and determine the sensitivity and specificity for identifying potentially violent patients in non-psychiatric inpatient units.

DESIGN

A prospective cohort study design was used.

METHODS

All patients admitted or transferred to three inpatient units of an acute care hospital in Nebraska, USA, from 7 February to 9 April 2023, were included. The 10-item ABRAT assessments were performed daily for the first 3 days of admission. The violent events were collected until discharge in three categories: Physical aggression towards others, physical aggression towards property and verbal intimidation/threat towards others. Kendall's tau tests and a multivariate logistic regression procedure were performed to select a parsimonious set of items that best predict violent events.

RESULTS

Of 1179 patients, 69 had ≥1 violent event (5.9%). The revised six-item tool with item weighting was named ABRAT for Hospitalised Patients (ABRAT-H). The area under the curve from the Receiver Operating Characteristics analysis was 0.82. The sensitivity and specificity at a cutoff score of two were 68.1% and 85.2%, respectively. As ABRAT-H scores increased, the percentage of violent patients also increased and for patients with scores ≥5, 55.2% became violent.

CONCLUSION

ABRAT-H appears to be useful for identifying potentially violent patients in non-psychiatric inpatient units with satisfactory sensitivity and specificity.

IMPLICATIONS FOR PATIENT CARE

The availability of ABRAT-H may help provide focused preventive measures that target patients at high risk for violence and reduce violent events.

IMPACT

A majority of the nursing workforce is employed in acute care hospital setting, and the availability of ABRAT-H can further enhance the culture of a safe work environment and have positive impacts not only on the nurses' physical and mental health but also on the quality of patient care.

REPORTING METHOD

We have adhered to relevant STROBE guidelines for reporting observational studies.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

[Psychiatric consultation and liaison sevices in the emergency department]

In somatic emergency departments, the prevalence of psychiatric emergencies is high, ranging from 5-10%. The psychiatric consultation and liaison service plays a central role in the interdisciplinary care of emergency patients in somatic emergency departments. It addresses patients primarily with psychiatric disorders, organically caused psychiatric conditions and somatic illnesses with psychiatric comorbidities. While consultation activities involve advising other medical disciplines, consultation and liaison services enable continuous treatment of patients. Depending on the organization as a consultation or combined consultation and liaison service, the aim is to ensure efficient, targeted, safe and cost-effective evaluation of psychiatric symptoms and/or to screen as many patients as possible with psychiatric symptoms, facilitating access to psychiatric treatment. Psychiatric consultation and liaison services can furthermore support decisions regarding necessary somatic evaluations prior to psychiatric treatment. The "SMART medical clearance form" provides a standardized approach to somatic evaluations for patients with psychiatric symptoms in emergency departments. To improve psychiatric assessments of patients in somatic emergency departments, further standardization of the recommended somatic examinations and the evaluation of whether somatic symptoms can be associated with an underlying psychiatric disorder are needed. In addition, guidelines should establish which patients require a psychiatric consultation assessment in emergency departments.

Characteristics and outcomes of consultation-liaison psychiatry referrals: A demographic and clinical analysis

BackgroundConsultation-liaison psychiatry (CLP) provides mental health expertise in general hospitals, where psychiatric comorbidities affect approximately 30% of patients. Following implementation of a new electronic referral system at Waikato Hospital, this study aimed to analyse referral quality and service utilisation patterns.MethodsA 12-month retrospective audit was conducted from July 2023 to June 2024, analysing all CLP referrals using a new system incorporating the Identify and Rate the Aim of the Contact (IRAC) tool and referral quality metrics. Referral quality was assessed both pre- and post-patient evaluation using a five-point Likert scale.ResultsOf 939 referrals (789 unique patients), 63.7% were rated as relevant to highly relevant. The average referral quality score was 2.698 pre-assessment and 2.682 post-assessment. General Medicine generated the most referrals, while Obstetrics/Gynaecology and Neurology showed lower quality scores. The mean time from admission to referral was 5.4 days. Risk assessment and management were the primary referral purposes, with 11.4% related to suicide attempts. Each referral averaged 3.64 contacts, with 20% of referrals consuming 54% of total contacts.ConclusionsWhile most referrals were appropriate, quality scores below three indicate room for improvement. Findings suggest the need for targeted educational interventions and feedback mechanisms to enhance referral quality and optimise resource allocation in CLP services.

Active Visual Art Therapy in the General Hospital: Facts and Challenges from an Ethical Perspective

For decades, art in its many forms has been used to improve patients' quality of life and mental health. A growing amount of literature has shown the effectiveness of active visual art therapy (AVAT) on different patient outcomes and highlighted the need for international collaboration and harmonization of research methods. Evidence regarding AVAT inside the general hospital is still limited. This context poses unique challenges in terms of feasibility, heterogeneity, settings, and type of participants, together with significant ethical implications in terms of humanization of care. This narrative review aimed to report the available data on the effectiveness of visual art therapy in the general hospital and discuss them through the lens of the key bioethical principles of autonomy, beneficence, non-maleficence, and justice introduced by Childress and Beauchamp. Current evidence supports the effectiveness of AVAT on children and adult inpatients' outcomes, particularly in the areas of pain control, anxiety, and depression, therefore supporting the individual's autonomy and beneficence. With regard to justice and equity, AVAT proved to be a safe and cost-effective adjunct intervention to medical management inside the hospital. A more in-depth understanding of the ethical aspects implied in using AVAT in the general hospital may add a further contribution to the implementation of art interventions in patient-centered care.

Socioeconomic inequalities, genetic susceptibility, and risks of depression and anxiety: A large-observational study

OBJECTIVES

This study aimed to investigate the interplay between genetic susceptibility and socioeconomic disparities on psychiatric disorders.

METHODS

In this study, we utilized data from the UK Biobank to analyze the Generalized Anxiety Disorder (GAD)-7 scale (N = 74,425) and the Patient Health Questionnaire (PHQ)-9 (N = 74,101), along with the Index of Multiple Deprivation (IMD). The polygenic risk score (PRS) was calculated to assess the genetic risk associated with GAD-7/PHQ-9 scores, and the individuals were classified into low, medium, and high genetic risk groups according to tertiles of PRSs related to the GAD-7/PHQ-9. Linear regression models were used to explore the relationships between GAD-7/PHQ-9 scores and IMD scores in patients with different genetic susceptibilities.

RESULTS

Disadvantaged socioeconomic status was associated with the risk of anxiety and depression across all strata of genetic risk, and stronger associations were shown for individuals with greater genetic susceptibility. From low to high genetic risk, the risk of psychiatric disorders increased for the GAD-7 (β = 0.002 to 0.032) and PHQ-9 (β = 0.003 to 0.045) scores. In addition, strong associations of high genetic risk with anxiety (β = 0.875) and depression (β = 1.152) were detected in the IMD quartile 4 group compared with the least deprivation quartile group. Furthermore, income and employment were estimated to contribute strongly to anxiety (βemployment = 7.331, βincome = 4.492) and depression (βemployment = 9.951, βincome = 6.453) in the high genetic risk group.

CONCLUSION

The results suggest that we should pay more attention to psychiatric disorders with high genetic susceptibility and try to improve their socioeconomic status to prevent the development of psychiatric disorders.

A Multifaceted Assessment of the Consultation Liaison Psychiatry Service Within a Regional Australian Hospital

BACKGROUND

Medical and mental health conditions have a reciprocal relationship, with each impacting the other. Consultation-liaison psychiatry (CLP) is a sub-speciality that addresses psychiatric comorbidities in the general hospital system and positively impacts hospital resources through its service aspects of 'consultation' and 'liaison'. This multi-faceted evaluation aims to describe and evaluate the characteristics of a regional CLP service.

METHODS

Retrospective evaluation of all referrals accepted by CLP between May 2021 and 2022 were reviewed through the hospital's electronic records. An evaluation tool was designed to assess multiple aspects of care, including the source of referrals, the reasons for referral, patient demographics, how quickly the patient was seen, information on their mental health, and the details and timeframe of CLP involvement.

FINDINGS

There were 147 patients included in this study. Doctors were the primary referrers (92%). A total of 94% of patients were reviewed within 24 h of the referral being received. Referral reasons were balanced across diagnostic clarification/review, medication review, and risk review. A large proportion of referrals were aged > 60 years. There was a large proportion of patients who lived rurally, requiring hospital transfer. CLP involvement was primarily required to provide a diagnosis (91% of patients) and provide pharmacological management advice (88%).

CONCLUSIONS

The CLP service currently operates with limited resources, and without additional support, the sustainability of the service will become increasingly challenged due to population ageing. It is essential that we address this issue to ensure that the community's needs are met effectively.

Psychiatric Diagnoses Are Associated With Postoperative Disparities in Patients Undergoing Major Colorectal Operations

BACKGROUND

Over 50% of hospitalized patients have comorbid psychiatric diagnoses, resulting in increased risk of morbidity such as longer lengths of stay, worse health-related quality of life, and increased mortality. However, data regarding colorectal surgery postoperative outcomes in patients with psychiatric diagnoses (PD) are limited.

METHODS

We queried a single institution's National Surgical Quality Improvement Program from 2013-2019 for major colorectal procedures. Postsurgical outcomes for patients with and without PD were compared. Primary outcomes were prolonged length of stay (pLOS) and 30-day readmission.

RESULTS

From a total of 1447 patients, 402 (27.8%) had PD. PD had more smokers (20.9% vs 15%) and higher mean body mass index (29.1 kg/m2 vs 28.2 kg/m2). Bivariate outcomes showed more surgical site infections (SSI) (10.2% vs 6.12%), reoperation (9.45% vs 6.35%), and pLOS (34.8% vs 29.0%) (all P values <.05) in the PD group. On multivariate analysis, PD had higher likelihood of reoperation (OR 1.53, 95% CI: [1.02-2.80]) and SSI (OR 1.82, 95% CI: [1.25-2.66]).

DISCUSSION

Psychiatric diagnoses are a risk factor for adverse outcomes after colorectal procedures. Further studies are needed to evaluate the benefit of perioperative mental health support services for these patients.

Mental Health Crisis Responses and (In)Justice: Intrasystem and Intersystem Implications

Mental health crises among people who are marginalized merit special consideration. These groups are both overserved and underserved by mental health crisis systems: over-represented in acute treatment settings by number while facing inequities in outcomes. The predisposing, precipitating, and perpetuating factors that contribute to crises, however, neither begin nor end with the mental health system. Rather, these factors are multisystemic. As an illustration of this concept, this article highlights select marginalized groups, those that have faced inequities in mental health diagnosis and treatment due to race, medical complexity, age, and criminal justice system involvement.

An Observational Study of Proactive and On-Request Psychiatry Consultation Services: Evidence for Differing Roles and Outcomes

BACKGROUND

Proactive psychiatric consultation services rapidly identify and assess medical inpatients in need of psychiatric care. In addition to more rapid contact, proactive services may reduce the length of stay and improve staff satisfaction. However, in some settings, it is impractical to integrate a proactive consultation service into every hospital unit; on-request and proactive services are likely to coexist in the future. Prior research has focused on changes in outcomes with the implementation of proactive services.

OBJECTIVE AND METHODS

This report describes differences between contemporary proactive and on-request services within the same academic medical center, comparing demographic and clinical data collected retrospectively from a 4-year period from the electronic medical record.

RESULTS

The proactive service saw patients over four times as many initial admissions (7592 vs. 1762), but transitions and handoffs between services were common, with 434 admissions involving both services, comprising nearly 20% of the on-request service's total contacts. The proactive service admissions had a shorter length of stay and a faster time to first psychiatric contact, and the patients seen were more likely to be female, of Black race, and to be publicly insured. There were over three times as many admissions to psychiatry from the proactive service. The on-request service's admissions had a longer length of stay, were much more likely to involve intensive care unit services, surgical services, and transfers among units, and the patients seen were more likely to die in the hospital or to be discharged to subacute rehabilitation.

CONCLUSIONS

Overall, the results suggest that the two services fulfill complementary roles, with the proactive service's rapid screening and contact providing care to a high volume of patients who might otherwise be unidentified and underserved. Simultaneously, the on-request service's ability to manage patients in response to consult requests over a much larger area of the hospital provided important support and continuity for patients with complex health needs. Institutions revising their consultation services will likely need to consider the best balance of these differing functions to address perceived demand for services.

Psychiatric Comorbidities in Neurologic Hospitalizations in Portugal: A Nationwide Retrospective Observational Study

INTRODUCTION

Psychiatric comorbidities have a significant impact on patients' quality of life and often go undetected in neurologic practice. The aim of this study was to describe and characterize psychiatric comorbidities among patients hospitalized due to a neurologic disorder in mainland Portugal.

METHODS

A retrospective observational study was performed by analyzing hospitalization with a primary diagnosis of neurologic disorder defined as categories 76, 77, 79 - 85, 95, 109 of the Clinical Classification Software for International Classification of Diseases, Ninth Revision, Clinical Modification, occurring between 2008 and 2015 in adult patients (≥ 18 years of age). Psychiatric comorbidities were determined as the presence of a secondary diagnosis belonging to the Clinical Classification Software categories 650 to 670.

RESULTS

A total of 294 806 hospitalization episodes with a primary diagnosis of a neurologic disorder were recorded in adult patients between 2008 - 2015 in Portuguese public hospitals. Approximately 26.9% (n = 79 442) of the episodes had a recorded psychiatric comorbidity (22.1%; 32.2%, female versus male hospitalizations). Patients with registered psychiatric comorbidities were younger (66.2 ± 16.2 vs 68.6 ± 17.2 with no psychiatric comorbidities, p < 0.001), presented lower all-cause in-hospital mortality rates, and significantly longer mean hospital stays. 'Delirium, dementia, amnestic and other cognitive disorders' were recorded in 7.4% (n = 21 965) of the hospitalizations, followed by alcohol-related disorders in 6.5% (n = 19 302) and mood disorders in 6.1% (n = 18 079). Epilepsy/seizures were the neurologic disorders with the highest proportion of recorded psychiatric comorbidities (39.9%).

CONCLUSION

Psychiatric comorbidities were recorded in more than a quarter of the hospitalizations with a primary diagnosis of a Neurologic disorder. Psychiatric comorbidities varied among neurological disorders and were associated with different demographic and clinical features.

Nursing assessment of mental health issues in the general clinical environment: A descriptive study

AIMS

To evaluate the effectiveness of a mental health screening form for early identification and care escalation of mental health issues in general settings. A secondary aim was to explore general nurses' use of the form and their confidence to discuss mental health issues with patients.

METHODS

A cross-sectional design comprising a review of clinical records to determine use of the form, instances of missed care and escalation to the mental health team. The survey focused on nurses' confidence in general settings to engage in discussions with patients about mental health. Data were collected from April to December 2022. The Strengthening the Reporting of Observational Studies in Epidemiology Statement guided this study.

RESULTS

Of 400 patient records, 397 were analysed; 293 (73.8%) of those had mental health screening by nurses. Age was a significant factor, with younger patients more likely to be screened although concerns were typically recognized in older patients. Of the 20 patients identified with mental health concerns, 9 (45%) were referred for further evaluation by the Clinical Liaison Team. While nurses were proactive in assessing physical risks, assessing risk factors that required deeper conversations with patients, including psychiatric history, was lacking. The survey highlighted fewer than half of the respondents (46%, n = 10) felt competent to engage in discussions about mental health; however, most (59%, n = 13) knew when to seek a mental health referral.

CONCLUSIONS

General nurses have a role in the early identification and referral of patients with mental health challenges. However, training is imperative to facilitate deeper patient interactions concerning mental health. Integrating mental health checks within general settings is crucial for early detection and intervention, aligning with global quality care standards.

REPORTING METHOD

STROBE guidelines.

PATIENT OR PUBLIC CONTRIBUTION

We received feedback that shaped the research protocol from a consumer representative.

Using Discrete Form Data in the Electronic Medical Record to Predict the Likelihood of Psychiatric Consultation

BACKGROUND

Manually screening for mental health needs in acute medical-surgical settings is thorough but time-intensive. Automated approaches to screening can enhance efficiency and reliability, but the predictive accuracy of automated screening remains largely unknown.

OBJECTIVE

The aims of this project are to develop an automated screening list using discrete form data in the electronic medical record that identify medical inpatients with psychiatric needs and to evaluate its ability to predict the likelihood of psychiatric consultation.

METHODS

An automated screening list was incorporated into an existing manual screening process for 1 year. Screening items were applied to the year's implementation data to determine whether they predicted consultation likelihood. Consultation likelihood was designated high, medium, or low. This prediction model was applied hospital-wide to characterize mental health needs.

RESULTS

The screening items were derived from nursing screens, orders, and medication and diagnosis groupers. We excluded safety or suicide sitters from the model because all patients with sitters received psychiatric consultation. Area under the receiver operating characteristic curve for the regression model was 84%. The two most predictive items in the model were "3 or more psychiatric diagnoses" (odds ratio 15.7) and "prior suicide attempt" (odds ratio 4.7). The low likelihood category had a negative predictive value of 97.2%; the high likelihood category had a positive predictive value of 46.7%.

CONCLUSIONS

Electronic medical record discrete data elements predict the likelihood of psychiatric consultation. Automated approaches to screening deserve further investigation.

Attitudes of Non-psychiatric Doctors Toward the Management of Psychiatric Problems

INTRODUCTION

This research explores non-psychiatric doctors' attitudes toward managing psychiatric problems, recognizing the critical intersection between physical and emotional health. The study aims to understand the barriers and facilitators in addressing these challenges within a tertiary care hospital in Hyderabad, India. The prevalence of psychiatric disorders among general hospital inpatients and outpatients underscores the need for comprehensive care. However, various obstacles hinder effective management. The objectives are to describe and understand these attitudes and to investigate the reasons for non-referral in cases involving psychiatric concerns.

METHODS

A cross-sectional study was conducted from April to May 2023, involving 178 doctors from various specialties directly engaged in patient care. Participants completed a modified Doctors Attitudes Toward Collaborative Care for Mental Health (DACC-MH) questionnaire. This tool assessed their attitudes toward psychosocial and psychiatric problems, including their willingness to take responsibility for assessments and referrals. Data analysis utilized the IBM Statistical Package for the Social Sciences (SPSS) Version 22 (IBM Corp., Armonk, NY). Descriptive statistics and chi-square tests were used to assess differences in attitudes based on demographics and specialties.

RESULTS

The study revealed predominantly positive attitudes among non-psychiatric doctors. Most acknowledged the importance of addressing patients' emotional problems (97.8%) and recognizing psychological factors' role in physical illnesses (96.1%). However, variations existed in the willingness to take responsibility for psychological assessments, especially in outpatient settings. Attitudes toward psychiatric referrals were generally positive, though differences were noted based on gender and specialization. Female doctors were more inclined toward emotional care, while male doctors were more willing to prescribe psychotropic drugs (p < 0.0001) and refer patients to psychiatrists. Physicians were more favorable toward emotional care, shared responsibility for emotional difficulties, and routine assessment of psychological and social factors. In contrast, surgical specialists restricted themselves to physical assessments (p < 0.0001).

CONCLUSION

 This research underscores the need for targeted educational initiatives and awareness campaigns to address the challenges in integrating mental healthcare into general healthcare contexts. Tailored programs, interprofessional collaborations, and efforts to reduce stigma are essential for improving doctors' attitudes and practices in managing psychiatric problems. Enhancing the integration of mental health care can lead to better patient outcomes and overall healthcare quality. Healthcare institutions can strive for more comprehensive, patient-centered care by understanding and addressing these attitudes.

Claims data analysis of the health care utilization for patients with coronary heart disease and mental comorbidity

OBJECTIVE

Mental disorders (MD) are a common comorbidity in patients with coronary heart disease (CHD) and have a significant impact on morbidity and mortality. The aim of this study was to determine to what extent mental disorders are diagnosed as comorbidity in patients with CHD and whether adequate therapeutic measures are taken.

METHODS

Claims data from 4435 Cologne citizens with diagnosed CHD and a hospital stay due to CHD in 2015 were examined through a longitudinal analysis. The data were analyzed descriptively with regard to mental disorders, investigating diagnostic examinations performed, prescriptions for psychotropic drugs, and utilization of psychotherapy. We differentiated between pre-existing MD, existing in the year before the CHD-related hospital stay, and incident MD with new onset during or within six months after hospitalization.

RESULTS

Psychodiagnostic examinations for mental disorders occurred very rarely during cardiological hospitalization (0.04%) and psychiatric/psychosomatic consultation sessions rarely (5%). The longitudinal analysis showed a high rate of pre-existing MDs (56%, n = 2490) and a new diagnosis of mental disorders in 7% (n = 302) of the patients. Within one year after inpatient treatment for CHD, psychotropic medication was prescribed in 64-67% of patients with newly diagnosed affective or neurotic, adjustment/somatoform disorder and 10-13% received outpatient psychotherapy.

CONCLUSION

The results indicate low rates of inpatient diagnostic examinations and low rates of adequate treatment of mental disorders in patients from Cologne with CHD and new onset mental disorders. The rate of prescriptions of psychopharmacotherapy after hospitalization due to CHD exceeds that of the utilization of outpatient psychotherapy.

Nurses' experiences of a screening and associated psychosomatic consultation service for mental comorbidities in somatic care inpatients - a qualitative study

Background

Screening for mental comorbidities and related liaison service can reduce hospital length of stay in somatic hospital care. To develop, test and sustain such health care services, stakeholder feedback is required. One of the most important stakeholders in general hospital care and health care processes are nurses.

Aim

The aim of this study is to explore nurses' experiencess on standardized nurse-led screening for mental comorbidities and associated psychosomatic consultation service in routine somatic inpatient care.

Method

Semi-structured qualitative interviews were conducted with 18 nurses that were involved in a nurse-led screening service for mental comorbidities on internal medicine or dermatological wards. Data were analyzed using thematic analysis.

Results

Eight thematic groups were developed. On the one hand, participants reported benefits of screening: mental health education, general mental health awareness, holistic treatment approach, opportunity to build rapport with patients and reduction in workload. On the other hand, possible psychological effects of the intervention, reasons why patients may not want to be referred and application requirements to facilitate delivery were identified. None of the nurses opposed screening and associated psychosomatic consultation service.

Conclusion

All nurses endorsed the screening intervention and considered it meaningful. Nurses particularly emphasized the potential for holistic patient care and nurses' improved skills and competencies, but partly critizised current application requirements.

Relevance to clinical practice

This study adds on existent evidence on nurse-led screening for mental comorbidities and associated psychosomatic consultation service by emphasizing its potential to improve both patient care as well as nurses' perceived self-efficacy and job satisfaction. To take full advantage of this potential, however, usability improvements, regular supervision, and ongoing training for nurses need to be considered.

Tracking Population-Level Anxiety Using Search Engine Data: Ecological Study

BACKGROUND

Anxiety disorders are the most prevalent mental disorders globally, with a substantial impact on quality of life. The prevalence of anxiety disorders has increased substantially following the COVID-19 pandemic, and it is likely to be further affected by a global economic recession. Understanding anxiety themes and how they change over time and across countries is crucial for preventive and treatment strategies.

OBJECTIVE

The aim of this study was to track the trends in anxiety themes between 2004 and 2020 in the 50 most populous countries with high volumes of internet search data. This study extends previous research by using a novel search-based methodology and including a longer time span and more countries at different income levels.

METHODS

We used a crowdsourced questionnaire, alongside Bing search query data and Google Trends search volume data, to identify themes associated with anxiety disorders across 50 countries from 2004 to 2020. We analyzed themes and their mutual interactions and investigated the associations between countries' socioeconomic attributes and anxiety themes using time-series linear models. This study was approved by the Microsoft Research Institutional Review Board.

RESULTS

Query volume for anxiety themes was highly stable in countries from 2004 to 2019 (Spearman r=0.89) and moderately correlated with geography (r=0.49 in 2019). Anxiety themes were predominantly long-term and personal, with "having kids," "pregnancy," and "job" the most voluminous themes in most countries and years. In 2020, "COVID-19" became a dominant theme in 27 countries. Countries with a constant volume of anxiety themes over time had lower fragile state indexes (P=.007) and higher individualism (P=.003). An increase in the volume of the most searched anxiety themes was associated with a reduction in the volume of the remaining themes in 13 countries and an increase in 17 countries, and these 30 countries had a lower prevalence of mental disorders (P<.001) than the countries where no correlations were found.

CONCLUSIONS

Internet search data could be a potential source for predicting the country-level prevalence of anxiety disorders, especially in understudied populations or when an in-person survey is not viable.