Clinical experience with the management of schizophrenia in the general hospital

Suicide attempts by jumping and length of stay in general hospital: A retrospective study of 225 patients

OBJECTIVE

Violent suicide attempts, such as jumping from a height, frequently lead to hospitalization in general hospital with high length of stay (LOS). We investigated features associated with LOS in this context.

METHODS

We retrospectively included all patients admitted after suicide attempts by jumping in non-psychiatric wards of a university hospital between 2008 and 2016. Several socio-demographic and clinical data were collected, including psychiatric diagnoses, coded with the International Classification of Diseases-10th Revision. We used general linear models to identify factors associated with LOS.

RESULTS

Among 225 patients (125 men; mean age ± sd: 37.5 ± 15.4 years), several clinical factors were independently associated with a longer LOS: number of injuries (β = 8.2 p < .001), external fixator (β = 18.1 p = .01), psychotic disorder (β = 14.6 p = .02) and delirium (β = 16.6 p = .005). Admission in psychiatric ward at discharge tended to be associated with lower LOS (β = -15.3 p = .07).

CONCLUSION

In patients admitted in non-psychiatric wards after suicide attempt by jumping, the presence of a psychotic disorder may increase LOS by several days, and indirectly costs of hospitalization, to a similar extent of non-psychiatric factors. The association of transfer in psychiatric ward with lower LOS suggests that the psychiatric disorder might interfere with medical care.

Capable of more: some underemphasized aspects of capacity assessment

BACKGROUND

The 4-abilities model of decision-making capacity is vulnerable to constricted application and teaching.

OBJECTIVE

The authors attempt to assert the fundamentally clinical nature of capacity evaluations, while acknowledging that the concept of decision-making capacity must be legally grounded.

METHODS

Relevant aspects of clinical care are examined and emphasized as they apply to the evaluation of capacity for medical decision making.

RESULTS

Accessing patients' maximal abilities, attending to noncognitive aspects of choice, and identifying diagnostic explanations for patients' difficulties are important components of these assessments.

DISCUSSION

The evaluation of medical decision-making capacity is not a purely forensic task; it is enhanced by an approach that bridges the clinical-forensic divide.

Palliative care for terminally ill individuals with schizophrenia

Individuals with schizophrenia are often medically undertreated and experience symptoms that interfere with communication and the capacity to make medical decisions. These issues complicate quality end-of-life care for this population and are of particular concern for hospice and palliative care nurses and health care providers. This article presents a case study of a terminally ill patient with schizophrenia. It is divided into a series of vignettes; each vignette presents a common clinical issue encountered by the palliative care team. Interventions suggested in the literature and those used by team members when working with the patient are discussed.

Delirium and decisional incapacity in veterans with schizophrenia and medical illness

OBJECTIVE

The objective was to examine the characteristics of Veterans with schizophrenia admitted for nonpsychiatric hospitalizations.

METHOD

We conducted a review of the electronic medical record and data warehouse downloads of Veterans with schizophrenia admitted to nonpsychiatric services of a large, academic Veterans Affairs hospital between 2004 and 2009 on whom psychiatry was consulted.

RESULTS

Seventy-four veterans were admitted 89 times. Their mean age was 62 years. Among these veterans, the most common reasons for nonpsychiatric admission were infection, cardiac disease or altered mental status. Thirty-three percent of consultations were for patients who required intensive care. Consultation was requested most frequently for assessing psychotropic medication, decision-making capacity or altered mental status, or for assistance with behavioral problems. Thirty-seven percent of patients were diagnosed with delirium, and 42% lacked decision-making capacity, mostly secondary to delirium. Twenty-seven percent of patients died during the study period.

CONCLUSION

In an aging cohort of Veterans with schizophrenia, a substantial proportion of patients developed delirium, lost decision-making capacity and required intensive care during nonpsychiatric hospital admission.

Do psychiatric departments in general hospitals have an impact on the physical health of mental patients?

PURPOSE OF REVIEW

Recent literature has increased awareness of the physical health problems that affect mental-health patients. The close association of psychiatric departments with other medical departments can lead to improved communication and support between all medical specialties. This review assesses the impact these developments have on the physical health of individuals with psychiatric disorders.

RECENT FINDINGS

The current literature shows that mentally ill individuals have increased physical illness comorbidity. They do not regularly attend screening programmes or follow-up appointments. They also have an increased incidence of unwanted events while hospitalized. These disturbing findings cannot be wholly explained by lifestyle factors and antipsychotic medication and it seems that stigma against mental illness has an effect as well.

SUMMARY

No evidence has emerged that the medical screening of psychiatric patients has improved overall. Psychiatrists may be coming more sensitive to the fact that their patients need close monitoring, not only of their mental state but also their blood pressure, sugar glucose and weight. Sensitizing clinicians to the needs of psychiatric patients is a slow procedure. There is a great need for studies on specific interventions aimed at specific medical conditions that coexist more frequently with psychiatric disorders.

Ownership, responsibility and hospital care: lessons for the consultation psychiatrist

OBJECTIVE

To identify scenarios in which consultation psychiatrists encounter difficulty reconciling their clinical role with consultees' expectations and to suggest concepts that help navigate these situations.

METHODS

The authors' clinical experiences are used to generate and discuss three major categories of situations that require psychiatric consultants to thoughtfully adjust the breadth and depth of their obligation to patients and consultees.

RESULTS

"Occam's razor 'dulled," "Conflation of the psychosocial with the psychiatric" and "Disposition preoccupation" are proposed as the major categories leading to conflicting patient management views between consultant and consultee. Each has, at its core, a compromise of patient ownership that blurs the boundaries of the consulting psychiatrist's responsibility.

CONCLUSIONS

Understanding and channeling ownership back to the consultee, while appropriately gauging and embracing one's responsibility, form a two-pronged approach to clarifying one's role in consultations.

Confidentiality in the age of HIPAA: a challenge for psychosomatic medicine

This review, a work project of The Standards and Ethics Committee of The Academy of Psychosomatic Medicine, examines the challenges posed for consultation-liaison psychiatrists as they struggle to maintain the trust between patient and physician while balancing compliance with the increasing complexities of confidentiality with the provision of enough information to our medical colleagues for good clinical care. The authors discuss the moral, legal, and ethical issues that arise from the many-layered state and federal regulations, especially the impact of the Health Information Portability and Accountability Act (HIPPA) and make recommendations for practical application in the clinical setting.