La psiquiatría de enlace y el diagnóstico del delirium tremens / Liaison psychiatry in diagnosing delirium tremens

La manifestación clínica más grave y potencialmente fatal de la abstinencia de alcohol es el delirium tremens (DT), cuadro observado en aproximadamente el 5% al 10% de los pacientes con trastorno por consumo de alcohol que requieren hospitalización. El diagnóstico adecuado del DT requiere conocer los factores de riesgo, el cuadro clínico típico y la evolución y la gravedad de los síntomas de abstinencia. Las benzodiazepinas son el tratamiento farmacológico de elección para los pacientes con DT. Su eficacia fue confirmada mediante numerosos estudios. Si bien hay drogas alternativas que también pueden ser efectivas, las benzodiazepinas son elegidas debido a su perfil farmacocinético y de seguridad favorable. Las drogas alternativas son utilizadas como complemento de las benzodiazepinas para el tratamiento de los pacientes con cuadros de abstinencia complicados o resistentes. Los esquemas que incluyen dosis de carga administradas por vía oral o intravenosa son los preferidos para los pacientes con DT. El aumento rápido de la dosis de benzodiazepinas de acuerdo con la gravedad de los síntomas evaluados mediante escalas estructuradas y el empleo de drogas adyuvantes alternativas permiten el control oportuno del DT. Cerca del 10% de los pacientes que presentan resistencia a las benzodiazepinas requieren tratamiento en unidades de terapia intensiva con dosis intravenosas elevadas de benzodiazepinas y otras drogas, evaluación minuciosa y, de ser necesario, ventilación mecánica. La suplementación vitamínica y la atención adecuada por parte del personal de enfermería también son componentes esenciales del tratamiento. Los psiquiatras de enlace deberían integrar equipos multidisciplinarios destinados al tratamiento agudo de los pacientes con DT. No obstante, solo los psiquiatras de enlace con capacidades y conocimiento que se desempeñan de acuerdo con los protocolos estandarizados pueden lograr que determinados pacientes con DT reciban tratamiento adecuado. El psiquiatra de enlace también debe procurar un periodo de abstinencia seguro que proteja la dignidad del paciente y lo prepare para resolver la dependencia

The most serious and potentially life-threatening manifestation of alcohol withdrawal is delirium tremens (DT) or alcohol withdrawal delirium, which occurs in about 5% to 10% of hospitalized patients with alcohol problems. A consideration of risk factors, the typical clinical picture, evolution of withdrawal-symptoms and their severity aid in the proper recognition of DT. Benzodiazepines are the mainstay of medication treatment of DT. Their efficacy has been established by a large body of evidence. Although alternative medications might be equally effective, benzodiazepines are preferred because of their favourable pharmacokinetic and safety. Alternative medications are used as adjuncts to benzodiazepines in the treatment of complicated and refractory withdrawal states. Oral or intravenous loading-dose regimens are preferred for treatment of DT. Rapidly escalating doses of benzodiazepines titrated to symptom-severity on structured scales and the use of adjunctive alternative medications ensures prompt control of DT. About 10% of patients who are benzodiazepine-resistant require treatment in intensive care units with massive intravenous doses of benzodiazepines and additional medications, careful monitoring and mechanical ventilation if necessary. Vitamin supplementation and adequate medical, nursing and supportive care are other essential components of management. Liaison psychiatrists are expected to form an integral part of the multidisciplinary team, which manages patients with DT in acute-care settings. Only skilled and knowledgeable liaison psychiatrists relying on standardized treatment protocols can make certain that patients with DT receive adequate care. The liaison psychiatrist also needs to ensure a safe and humane withdrawal that protects the patient's dignity and prepares the patient for on-going treatment of dependence.

Lifestyle related factors & impact of metabolic syndrome on quality of life, level of functioning & self-esteem in patients with bipolar disorder & schizophrenia.

Background & objectives: Though studies have reported high prevalence rates of metabolic syndrome among patients with bipolar disorder (BPAD) and schizophrenia, there is lack of data on the impact of the same on the patients’ life. This study was aimed to assess the lifestyle related factors associated with metabolic syndrome (MetS) and to study the impact of MetS on functioning and quality of life (QOL) in patients with BPAD and schizophrenia. Methods: A total of 102 patients with BPAD and 72 patients with schizophrenia attending the output unit of a tertiary care hospital in north India were evaluated for MetS. These patients were assessed on Health Promoting Lifestyle Profile scale II (HPLP II), World Health Organization QOL -Bref Version (WHOQOL-Bref), Impact of Weight on Quality of Life- Lite version (IWOQOL -Lite), Body weight, Image and Self-esteem Evaluation questionnaire (BWISE), Obesity-related Problem scale (OP scale) and Global Assessment of Functioning (GAF) scale. Results: MetS was associated with lower scores on domains of health responsibility and nutrition habit domain on HPLP-II scale in both groups, and additionally on physical activity and stress management domain in BPAD group. On WHOQOL-Bref, MetS was associated with lower scores on the domains of physical and psychological health in both groups. On IWQOL–Lite, scores on personal distress and self esteem domains were higher in those with obesity in both groups and also on physical activity domain in schizophrenia group. Those with MetS had lower level of functioning as measured by GAF in schizophrenia group. Fulfillment of higher number of criteria of MetS correlated with poorer quality of life and higher problems in both groups. Interpretation & conclusions: Many modifiable lifestyle factors increase the risk of MetS. MetS was found to be associated with poorer QOL in patients with BPAD and schizophrenia; in addition, obesity led to poor self-esteem and excessive personal distress.