Integrating Psychiatric Services in the Emergency Room to Improve Patient Care by Using Quality Improvement Methods.

ABSTRACT: Prolonged length of stay in emergency departments (EDs) for patients with a psychiatric chief complaint is a widespread problem. Prolonged stays can lead to adverse outcomes and poor quality of care. We sought to improve quality of care for patients in the medical ED who needed psychiatric care. To identify the areas of weakness, we queried the ED staff via an online survey about the perception of the challenges working with our Comprehensive Psychiatric Emergency Program (CPEP), which is located adjacent to and works closely with the medical ED providing psychiatric consultation. We identified several action steps and used the Plan-Do-Study-Act methodology for implementation. We reported a reduction in time to complete consultations and improved communication between CPEP and the medical ED staff.

Consideration of Factitious Disorder in Management of Patients With Autoinflammatory Disease.

ABSTRACT: Factitious disorder, a disorder characterized by the falsification of symptoms to obtain primary gain, continues to be one of the more challenging cases that psychiatrists encounter. We describe a case of a woman we treated on the medical unit who falsified several of her symptoms but also was diagnosed with Yao syndrome, a disease that can also cause unexplained symptoms such as abdominal pain and fever. We navigate the difficulties in managing this type of patient and comanaging her with medicine and rheumatology. Although the prevalence of factitious disorder is anywhere from 1% to 2% of patients on the medical floor, they typically utilize a disproportionate number of resources. Despite this, the literature is still inconclusive when it comes to the management and treatment approaches. More study is warranted on this complex and burdensome illness.

Can bupropion treat COVID-19-induced brain fog? A case series.

COVID-19-induced neurocognitive complications that include brain fog have affected a large portion of individuals who survived COVID-19. These symptoms can include inattention, mental fatigue, forgetfulness, amotivation, and distractibility. This can cause significant anxiety and depression, which may worsen disease progression. To date, there are no known specific treatments that target COVID-19-related brain fog. Here, two patients are presented that develop symptoms of brain fog that persisted after they recovered from an acute COVID-19 infection. Both had memory impairment, mental exhaustion, and inattention with associated depressed mood. They were given bupropion extended release and though varied with dosing and time to resolution, they recovered dramatically. The dopamine and norepinephrine reuptake inhibitor is known to have effects on the brain that may treat symptoms of brain fog including blocking hippocampal cell loss, increased neural activity in the cingulate cortex, and decreasing proinflammatory cytokines. Bupropion may be a possible option for those suffering from this growing and debilitating post-COVID-19 complication.

Diagnostic overshadowing clouding the efficient recognition of pediatric catatonia: a case series.

Catatonia is a neuropsychiatric condition that causes disruption of movement, emotion, and behaviors. Children and adults with underlying psychiatric conditions are particularly susceptible to developing catatonia, which may result in medical and psychiatric complications. Although catatonia research has been growing at a rapid rate in the last 20 years, it continues to be met with inefficiencies in its diagnosis and incertitude in its treatment. In the pediatric population, catatonia is plagued by diagnostic overshadowing, where the catatonia is erroneously attributed to existing pathologies that lead to a prolonged disease state. This paper describes three pediatric patients with catatonia that fell victim to diagnostic overshadowing. More rigorous training and education are imperative to improve the efficient recognition and treatment of children with catatonia.

An Examination of Electroconvulsive Therapy and Delivery of Care in Delirious Mania.

OBJECTIVES: Delirious mania is a severe life-threatening syndrome, often misdiagnosed, and eminently treatable as a variant of catatonia. Our aim is to provide a comprehensive examination of electroconvulsive therapy (ECT) parameters and clinical features, as well as describe the delivery of care of the patients with delirious mania. METHODS: A retrospective study was conducted of the ECT records at Stony Brook University Hospital from years 2014 to 2021. We characterized demographic and clinical variables, including psychiatric diagnoses and ECT parameters of patients identified with delirious mania. RESULTS: We identified 8 cases (3 women) of delirious mania with 8 corresponding acute treatment series. The mean age was 43.2 ± 12.6 years (range, 23-59 years). There were a total of 55 sessions performed with an average of 6.9 ± 2.6 (range, 5-13); 45 (82%) were bilateral (bifrontal or bitemporal) and 10 (18%) were right unilateral electrode placement. In 40 (73%) of the sessions, a high-energy stimulus was used (>60%, or 302 millicoulombs). Seizure duration measured on electroencephalogram was 47.4 ± 25.9 seconds (range, 0-143 seconds). Motor seizure duration measured on electromyogram was 32.7 ± 14.9 seconds (range, 0-66 seconds). In 6 cases, ECT was delayed for 10 days, and patients were given inappropriate treatments. High-dose antipsychotics caused worsened aggression and hemodynamic instability requiring physical restraints in 50% of cases. CONCLUSIONS: The clinical presentation of delirious mania remains poorly recognized, and its treatment is often delayed, which may result in negative outcomes. Bilateral ECT with high-energy dosing yielded a rapid remission of symptoms.

Case series on aripiprazole and dopamine supersensitivity psychosis.

A potential link between switching to aripiprazole and worsening of psychosis was first reported in the early 2000s. There have since been numerous published case reports describing this phenomenon, but only recently has the concept of a theoretical aripiprazole-induced dopamine supersensitivity psychosis (DSP) caused by D2 receptor activation in patients undergoing a switch to aripiprazole appeared in the literature. There is less awareness in clinical practice of the possibility of inducing DSP with aripiprazole, which may be particularly severe in some patients. The objective of this article is to present four cases demonstrating rapid and dramatic onset of DSP during switching to aripiprazole. In each case, a patient with a Diagnostic and statistical manual of mental disorders (5th ed.) diagnosis of schizophrenia experienced severe worsening of psychosis within 4-5 days of abrupt switching to aripiprazole from a full D2 antagonist. To our knowledge, this is the first case series characterizing the previously well-documented worsening of psychosis during switching to aripiprazole specifically as aripiprazole-induced DSP. We discuss clinical relevance, prevention and future directions. Careful cross-titration per clinical practice guidelines may reduce occurrence of DSP during aripiprazole switching or augmentation treatment.