Multinational perspectives on changes to psychiatric care during the COVID-19 pandemic: a survey of practicing psychiatrists.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has resulted in significant upheaval in psychiatric care. Despite survey data collected from psychiatric patients and broad samples of individuals in single countries, there is little quantitative or qualitative data on changes to psychiatric care from the perspective of mental health providers themselves across developing countries. METHODS: To address this gap, we surveyed 27 practicing psychiatrists from Central and Eastern Europe, as well as Africa, the Middle East, and Latin America. RESULTS: Respondents observed a marked increase in anxiety in their patients, with increased (though less prominent) symptoms of depression, somatization, and addiction. They reported largescale changes in the structure of psychiatric treatment, chiefly a decline in psychiatric admissions and closing/repurposing of psychiatric beds. Results supported strong "buy in" from clinicians regarding the use of telehealth, though some clinicians perceived a reduction in the ability to connect with, and build alliances with, their patients. Finally, clinicians described an improvement in the image and meaning of psychiatry in society, increased awareness of mental illness, and greater value placed on mental health in the general population. CONCLUSIONS: These changes warrant further empirical study as to their potential long-term ramifications, particularly as the COVID-19 pandemic persists and new waves of infection occur periodically throughout the world. The increased psychiatric burden on the population coupled with the apparent salience of mental health and well-being in the public consciousness represents a global opportunity for psychiatry to advocate for further treatment, research, and education.

Abnormal thyroid function tests in psychiatric patients: a red herring?

Thyroid abnormalities can induce mood, anxiety, psychotic, and cognitive disorders. Thus, thyroid function tests are routinely checked in psychiatric patients. However, up to one-third of psychiatric patients may demonstrate thyroid function test abnormalities that do not reflect true thyroid disease, but rather are a manifestation of secondary effects on one or more levels of the hypothalamic-pituitary-thyroid (HPT) axis. Originally termed the euthyroid sick syndrome, this phenomenon is now more commonly referred to as "non-thyroidal illness." In psychiatric patients with non-thyroidal illness, patterns of thyroid function test abnormalities may vary considerably based upon factors such as the underlying psychiatric disorder, the presence of substance abuse, or even the use of certain psychiatric medications. Thus, any abnormal thyroid function tests in psychiatric patients should be viewed with skepticism. Given the fact that thyroid function test abnormalities seen in non-thyroidal illness usually resolve spontaneously, treatment is generally unnecessary, and may even be potentially harmful.

Physician staffing for the practice of psychosomatic medicine in general hospitals: a pilot study.

BACKGROUND: The treatment of psychiatric illnesses, prevalent in the general hospital, requires broadly trained providers with expertise at the interface of psychiatry and medicine. Since each hospital operates under different economic constraints, it is difficult to establish an appropriate ratio of such providers to patients. OBJECTIVE: The authors sought to determine the current staffing patterns and ratios of Psychosomatic Medicine practitioners in general hospitals, to better align manpower with clinical service and educational requirements on consultation-liaison psychiatry services. METHOD: Program directors of seven academic Psychosomatic Medicine (PM) programs in the Northeast were surveyed to establish current staffing patterns and patient volumes. Survey data were reviewed and analyzed along with data from the literature and The Academy of Psychosomatic Medicine (APM) fellowship directory. RESULTS: Staffing patterns varied widely, both in terms of the number and disciplines of staff providing care for medical and surgical inpatients. The ratio of initial consultations performed per hospital bed varied from 1.6 to 4.6. CONCLUSION: Although staffing patterns vary, below a minimum staffing level, there is likely to be significant human and financial cost. Efficient sizing of a PM staff must be accomplished in the context of a given institution's patient population, the experience of providers, the presence/absence and needs of trainees, and the financial constraints of the department and institution. National survey data are needed to provide benchmarks for both academic and nonacademic PM services.

A comparison of psychiatric consultation between geriatric and non-geriatric medical inpatients.

OBJECTIVE: The authors examine changes in psychiatric referral patterns for geriatric inpatients since last reported in the United States, more than 20 years ago, and compare geriatric psychiatric referrals to those of a non-geriatric cohort. METHOD: Retrospective study comparing psychiatric diagnosis, treatment and aftercare of younger (ages 18-60 years, n = 474) and older (>60 years, n = 487) patients seen in psychiatric consultation in a large, urban, university-based tertiary care hospital setting. RESULTS: Compared to previous reports in the literature, this cohort contains a notably higher percentage of the 'old-old' (>80 years), reflecting the general aging of those who are hospitalized. Compared to younger patients, geriatric inpatients were more commonly referred for psychiatric consultation, but overall rates of referral remain low (<4%). Geriatric patients were diagnosed with dementia and delirium more frequently; with substance dependence less frequently; and were just as likely to be diagnosed with depression. Geriatric patients were also more likely to receive atypical antipsychotic medications and less likely to receive benzodiazepines than younger patients. In patients diagnosed with depression, psychiatric follow-up is more likely relegated to outpatient geriatricians and nursing homes. CONCLUSIONS: Consulting psychiatrists frequently encounter geriatric patients and, given patterns of diagnosis and aftercare, should play a major role in medical staff education and in development of enhanced in-hospital and aftercare services, including psychiatric liaison.

Acute mania in the setting of severe hypothyroidism.

Although the associations between depression and hypothyroidism and between mania and hyperthyroidism are well described, mania in the setting of hypothyroidism is unusual. The authors present the case of a patient whose acute mania appears to have been precipitated by hypothyroidism secondary to postpartum thyroiditis. This case underscores the importance of thyroid screening in patients with mood and psychotic disorders, including patients who lack the classical psychiatric features of thyroid dysfunction. Further investigation is required on the nature of the relationship between thyroid function and bipolar disorder and any implications it may have for the diagnosis and treatment of this illness.

The clock drawing test: diagnostic, functional, and neuroimaging correlates in older medically ill adults.

This study evaluated the clock drawing test (CDT), a screening test sensitive to executive function, in 70 elderly psychiatric consultation patients. The CDT was compared to the Mini-Mental Status Examination (MMSE) on associations with psychiatric diagnoses, disposition status and radiographic findings. CDT and MMSE were correlated, and scores differed across psychiatric subgroups. In multivariate analysis, only age and CDT predicted disposition status. A lower CDT score correlated with a higher intercaudate ratio, indicating greater caudate atrophy. These findings suggest that the CDT indicates underlying subcortical pathology and deficiencies in executive function important for self-care.