Performance measurement tools for consultation-liaison psychiatry services must consider feasibility.

This editorial describes an effort by 9 consultation-liaison (C-L) psychiatry service leaders in the United States to incorporate routine performance measurement into their service workflows. Although C-L psychiatry is an essential clinical service in general hospitals, performance metrics for this service have not been broadly accepted or implemented. Meanwhile, the performance metrics that have been developed rely on an investment in resources and/or new workflows that C-L psychiatry services may not be prepared to make on a widespread level. Our group sought to determine the feasibility of incorporating routine performance measurement into the workflows of a diverse sample of C-L psychiatry services using only existing resources via three collection methods: timestamp review, chart auditing, and survey administration. No methods were broadly successful across the 9 services. We argue that for routine performance measurement to gain wider traction in the field of C-L psychiatry, the ready availability-or automatability-of performance data must be taken into account.

Designing an Academic-Community Telepsychiatry Partnership to Provide Inpatient and Outpatient Services in a Critical Access Hospital.

To expand access to mental health treatment in an underserved area, the University of Washington (UW) and Dayton General Hospital (DGH) entered into a partnership to provide comprehensive telepsychiatry services to individuals living in rural Columbia County. Outpatient care is provided by behavioral health consultants at two DGH-affiliated primary care clinics in consultation with a UW-based psychiatrist with expertise in addictions. Inpatient care is supported by regular consultation with UW psychiatrists as well as unscheduled "curbside" consults with attending UW psychiatrists. Patients with complex treatment options can participate in direct videoconferencing sessions with a UW psychiatrist.

Telepsychiatry by a Public, Academic Medical Center for Inpatient Consults at an Unaffiliated, Community Hospital.

BACKGROUND: Telepsychiatry has the potential to help address the uneven distribution of psychiatrists between urban and rural areas. While telepsychiatry has been used for several decades, employing video conferencing technologies to conduct psychiatry consults to the medical wards of rural hospitals is a more recent application. OBJECTIVE: To develop the first US program wherein psychiatrists covering the consult service at a public, academic medical center also delivered same-day consults to patients on the medical wards of unaffiliated, rural hospitals. METHODS: We describe the rationale, workflow, technology, case distribution, benefits, and lessons learned from the first 24 months of the service. RESULTS: The program resulted in 156 initial and follow-up consults wherein patient interviews were conducted via live videoconference. An additional 19 "curbside" consults were done via hospitalist-to-psychiatrist phone calls. Though the initial impetus for the development of the program was to manage involuntarily-detained patients awaiting the availability of a psychiatric bed, the availability of the psychiatrists resulted in the service being used for a wide range of situations and diagnoses. CONCLUSION: Given the benefits noted by consultants, patients, and community hospital medical staff, the program could be replicated by other institutions.

Demographic and clinical factors associated with benzodiazepine prescription at discharge from psychiatric inpatient treatment.

OBJECTIVE: We sought to characterize diagnostic and treatment factors associated with receiving a prescription for benzodiazepines at discharge from a psychiatric inpatient unit. We hypothesized that engaging in individual behavioral interventions while on the unit would decrease the likelihood of receiving a benzodiazepine prescription at discharge. METHOD: This is an observational study utilizing medical chart review (n=1007) over 37 months (2008-2011). Descriptive statistics characterized patient demographics and diagnostic/prescription frequency. Multivariate regression was used to assess factors associated with receiving a benzodiazepine prescription at discharge. RESULTS: The sample was 61% female with mean age=40.5 (S.D.=13.6). Most frequent diagnoses were depression (54.7%) and bipolar disorder (18.6%). Thirty-eight percent of participants engaged in an individual behavioral intervention. Benzodiazepines were prescribed in 36% of discharges. Contrary to our hypothesis, individual behavioral interventions did not influence discharge benzodiazepine prescriptions. However, several other factors did, including having a substance use disorder [odds ratio (OR)=0.40]. Male sex (OR=0.56), Black race (OR=0.40) and age (OR=1.03) were nonclinical factors with strong prescribing influence. CONCLUSION: Benzodiazepines are frequently prescribed at discharge. Our results indicate strong racial and sex biases when prescribing benzodiazepines, even after controlling for diagnosis.

Manually locating physical and virtual reality objects.

OBJECTIVE: In this study, we compared how users locate physical and equivalent three-dimensional images of virtual objects in a cave automatic virtual environment (CAVE) using the hand to examine how human performance (accuracy, time, and approach) is affected by object size, location, and distance. BACKGROUND: Virtual reality (VR) offers the promise to flexibly simulate arbitrary environments for studying human performance. Previously, VR researchers primarily considered differences between virtual and physical distance estimation rather than reaching for close-up objects. METHOD: Fourteen participants completed manual targeting tasks that involved reaching for corners on equivalent physical and virtual boxes of three different sizes. Predicted errors were calculated from a geometric model based on user interpupillary distance, eye location, distance from the eyes to the projector screen, and object. RESULTS: Users were 1.64 times less accurate (p < .001) and spent 1.49 times more time (p = .01) targeting virtual versus physical box corners using the hands. Predicted virtual targeting errors were on average 1.53 times (p < .05) greater than the observed errors for farther virtual targets but not significantly different for close-up virtual targets. CONCLUSION: Target size, location, and distance, in addition to binocular disparity, affected virtual object targeting inaccuracy. Observed virtual box inaccuracy was less than predicted for farther locations, suggesting possible influence of cues other than binocular vision. APPLICATION: Human physical interaction with objects in VR for simulation, training, and prototyping involving reaching and manually handling virtual objects in a CAVE are more accurate than predicted when locating farther objects.

Psychosis from subthalamic nucleus deep brain stimulator lesion effect.

BACKGROUND: Deep brain stimulation (DBS) of the subthalamic nucleus (STN) in particular is highly effective in relieving symptoms of Parkinson's disease (PD). However, it can also have marked psychiatric side effects, including delirium, mania, and psychosis. The etiologies of those effects are not well-understood, and both surgeons and consulting psychiatrists are in need of treatment strategies. CASE DESCRIPTION: Two patients with young onset of PD and without significant prior psychiatric problems presented for bilateral STN DBS when medications became ineffective. Both had uneventful operative courses but developed florid psychosis 1-2 weeks later, before stimulator activation. Neither showed signs of delirium, but both required hospitalization, and one required treatment with a first-generation antipsychotic drug. Use of that drug did not worsen PD symptoms, contrary to usual expectations. CONCLUSION: These cases describe a previously unreported post-DBS syndrome in which local tissue reaction to lead implantation produces psychosis even without electrical stimulation of subcortical circuits. The lesion effect also appears to have anti-Parkinsonian effects that may allow the safe use of otherwise contraindicated medications. These cases have implications for management of PD DBS patients postoperatively, and may also be relevant as DBS is further used in other brain regions to treat behavioral disorders.

Is antidepressant-associated mania always an evidence of a bipolar spectrum disorder? A case report and review of the literature.

OBJECTIVE: The authors consider the clinical implications of characterizing every case of antidepressant-induced mania as evidence of an underlying bipolar diathesis. METHOD: The authors report the case of a 45-year-old man, with no personal or family history of bipolar symptoms, who developed manic symptoms after sertraline initiation for a first lifetime depressive episode. RESULTS: The patient's manic symptoms resolved rapidly with cessation of sertraline. His depressive symptoms responded to mirtazapine, and he had no further mood episodes during 2-year follow-up. DISCUSSION: It may not always be appropriate to identify selective serotonin reuptake inhibitor-induced manic symptoms as pathognomonic for the bipolar diathesis, particularly as the bipolar formulation has distinct implications for future pharmacologic choices.

A peer mentoring group for junior clinician educators: four years' experience.

PURPOSE: To study the effect of a peer mentoring group (PMG). METHOD: Six junior clinician educator faculty and one senior faculty at the University of Washington Medical Center's Department of Psychiatry formed a PMG in 2006. The PMG had 30 meetings during 2006-2010. Group format, goals, and meeting agendas were determined solely by participants. Feedback about positive and negative outcomes of participation in the PMG was determined by open-ended response to three sets of questions; qualitative analysis was performed by an outside research consultant. RESULTS: Program evaluation revealed benefits and undesirable or unintended outcomes. Reported benefits were increased workplace satisfaction; improved social connection; increased professional productivity and personal growth/development through accountability, collaboration, mutual learning, support, and information sharing; synergy, collaboration, and diversity of thought; increased involvement in professional activities; opportunity for peer discussions in a safe environment; and increased accountability and motivation. Undesirable or unintentional outcomes were exclusivity, lack of hierarchy, scheduling of meetings, absence of an intentional curriculum, diverse and competing interests, personal-professional enmeshment, and occasional loss of focus due to overemphasis on personal matters. Every member of the PMG was retained, and scholarly productivity increased, as did collaboration with other group members. CONCLUSIONS: Participants in this PMG experienced qualitative benefits and perceived advantages in career advancement and scholarly productivity. Negative consequences did not deter participation in the PMG or outweigh benefits. The self-sufficient and low-cost structure makes it particularly portable.

Virtual Exertions: a user interface combining visual information, kinesthetics and biofeedback for virtual object manipulation.

Virtual Reality environments have the ability to present users with rich visual representations of simulated environments. However, means to interact with these types of illusions are generally unnatural in the sense that they do not match the methods humans use to grasp and move objects in the physical world. We demonstrate a system that enables users to interact with virtual objects with natural body movements by combining visual information, kinesthetics and biofeedback from electromyograms (EMG). Our method allows virtual objects to be grasped, moved and dropped through muscle exertion classification based on physical world masses. We show that users can consistently reproduce these calibrated exertions, allowing them to interface with objects in a novel way.

Cosegregation of bipolar disorder and autosomal-dominant medullary cystic kidney disease in a large family.

OBJECTIVE: The authors report a large family in which bipolar disorder appears to cosegregate with autosomal-dominant medullary cystic kidney disease. METHOD: Information regarding diagnostic criteria for bipolar disorder and medullary cystic kidney disease were gathered from family members through formal research interviews, hospital admission records, imaging reports, and laboratory data. RESULTS: Of the seven members with medullary cystic kidney disease, five had bipolar I disorder, one had unipolar depression, and one had a hyperthymic phenotype. Information was not available on two members. CONCLUSIONS: The cosegregation in this family suggests a close proximity between genes for the two disorders. The two known loci of medullary cystic kidney disease are in regions of chromosomes 1 and 16 that have been previously linked to bipolar disorder and schizophrenia. This family may be a useful resource for positional cloning of bipolar candidate genes.

Valproic acid-associated hyperammonemic encephalopathy: a case report from the psychiatric setting.

Valproic acid-associated hyperammonemic encephalopathy (VHE) has been described in the neurology and emergency medicine literature, but the case reports identified therein are rarely derived from the psychiatric use of this medication. Valproic acid is widely used as a mood stabilizer in bipolar affective disorder and schizoaffective disorder. Patients with normal blood levels, liver function and metabolic tests may present with markedly elevated ammonia and a variety of neurological symptoms. We report the case of a patient on long-term valproic acid therapy, with stable dosing, who presented with an elevated ammonia level, new-onset tremor, confusion, and loss of consciousness. This case illustrates the need to check ammonia levels in psychiatric patients who are taking valproic acid and who present with new neurological symptoms.