Psychotropic Polypharmacy among Elderly Patients with Mental Illness in a Malaysian University Hospital: A 10-Year Review of Hospital Databases

Psychotropic polypharmacy among elderly patients is problematic due to their multiple comorbidities. This study investigated psychotropic polypharmacy among elderly patients discharged from a Malaysian university hospital and its associated factors. Discharges of patients aged 65 years or above from the psychiatric wards from 2010 to 2019 were reviewed. Sociodemographic data, length of stay (LOS), psychiatric and other diagnoses, and psychotropic prescription upon discharge were extracted from electronic databases. Multiple logistic regression was conducted with age, gender, race, marital status, main psychiatric diagnosis, LOS, and the number of medical comorbidities as independent variables, and polypharmacy (>2 psychotropics) as the dependent variable. There were 354 discharges in this period. The mean age was 72.4 years (SD=5.9 years); 63.0% were female and 39.8% were Malays. Most were married (84.2%). The commonest category of psychiatric diagnosis was mood disorders (54.5%). A total of 76.8% of the discharges involved one or more medical comorbidities. The median number of psychotropics was two, with 38.1% prescribed three or more psychotropics. In the multiple regression model, female gender, Malay race, and being married were significantly associated with psychotropic polypharmacy. Sociocultural factors may contribute to psychotropic polypharmacy among elderly patients. Such factors require further investigations to elucidate their roles.

Four Core Concepts in Psychiatric Diagnosis

In the present article, we aimed at describing the diagnostic process in Psychiatry through a phenomenological perspective. We have identified 4 core concepts which may represent the joints of a phenomenologically oriented diagnosis. The “tightrope walking” attitude refers to the psychiatrist’s ability to swing between 2 different and sometimes contrasting tendencies (e.g., engagement and disengagement). The “holistic experience” includes all those intuitive, nonverbal, and pre-thematic elements that emerge in the early stages of the clinical encounter as an emanation of the atmospheric quality of the intersubjective space. The “co-construction of symptoms” regards the hermeneutic process behind psychiatric symptoms, involving both the patient as a self-interpreting agent and the clinician as a translator of his/her experience. Finally, by the “evolving typification” we mean that the closer the relationship becomes with the patient, the more specific and nuanced becomes the typification behind psychiatric diagnosis. Each of these concepts will be accompanied by an extract from a clinical case deriving from one of the authors’ most recent clinical experiences.

A System-wide Retrospective Cohort Analysis of Psychiatric Diagnoses and Persistent Symptoms Following Concussion

ObjectiveTo evaluate the epidemiologic features of psychiatric comorbidities following mild traumatic brain injury (MTBI, or concussion) in a state-wide hospital system cohort over a 10-year period.BackgroundThe epidemiology of neuropsychiatric symptoms and diagnoses following concussion are poorly understood. Despite the rebirth of post-concussion syndrome (PCS) as persistent post-concussion symptoms (PPCS), entailing diverse and complex somatic, cognitive, and emotional components with significant potential overlap or confounding of psychiatric comorbidities, there is scarce characterization of the incidence of such comorbidities following concussion. The study of demographic factors as they relate to psychiatric diagnoses following concussion remains in infancy.Design/MethodsWe conducted an observational retrospective cohort study of all patients who received a diagnosis of concussion within Ochsner Health (OH) over a 10-year period. System-wide electronic medical records were evaluated using ICD-10 codes to collect data on patients with a diagnosis of MTBI or concussion, as compared to patients with no diagnosis of concussion over the same period. Data on subpopulations corresponding to psychiatric diagnostic outcomes following diagnosis of concussion were collected and evaluated to determine timeline-related incidences of outcomes, as well as on demographic and morbid features corresponding to each outcome. These included age, sex, race, ethnicity, household income, neurologic and psychiatric history, cause of concussion, and presence of loss of consciousness.ResultsWe report incidence, demographic, and morbid factor data on patients with a diagnosis of concussion, and as related to outcomes following diagnosis of concussion, including: (1) new diagnosis of PCS, (2) meeting PPCS Berlin Sport Concussion Consensus criteria, (3) new unclassified neuropsychiatric symptoms, (4) any new psychiatric diagnosis, (5) new psychiatric diagnosis excluding PCS, (6) new anxiety, dissociative, stress-related, or somatoform disorder diagnosis, (7) new reaction to severe stress or adjustment disorder diagnosis, and (8) new PTSD diagnosis.ConclusionsWe call for multidisciplinary awareness, screening, and longitudinal research of patients with concussion.

The Lost Years 1918-1935

The article covers the last 17 years of Komitas’s life. Constantinople Armenians who took care of Komitas, on the advice of Dr. Vahram Torkomian, seeing no improvement in Komitas’s mental health, while he was treated at Hopital de la Paix in Istanbul, decided to send him to Paris, hoping for better treatment and outcome. The article describes Komitas’s medical care, both psychiatric and physical until his death in 1935 when Komitas was in custodial care in Paris sanatoriums. It describes and analyses the findings from Komitas’s medical files at Ville- Evrard and Ville- Juif Hospitals. It reviews the psychiatric consultations, and explains the medical terms used at the beginning of the 20th century and its implications for psychiatric diagnosis used in Western psychiatry of today. Finally it describes his death due the bone infection in his foot and his funeral arrangements. Սույն հոդվածը նկարագրում է Կոմիտասի կյանքի և հիվանդության փարիզյան շրջանը մինչև իր մահը 1935 թ․ հոկտեմբերին։ 1918 թ. Զինադադարից հետո Կոմիտասի ընկերները բժիշկ Վահրամ Թորգոմյանի խորհրդով նրան բուժման նպատակով ուղարկում են Փարիզ։ Կոստանդնուպոլսի Լա Բե հիւանդանոցում Կոմիտասի առողջությունն անփոփոխ էր մնում, և լավացում չէր արձանագրվում։ Հոդվածն անդրադառնում է Փարիզի Վիլ Էվրար և Վիլ Ժուիֆ բուժական հաստատություններում Կոմիտասի բժշկական խնամքին։ Վերլուծության են ենթրկվում բժշկական թղթապանակը, բժշկական խորհրդատվությունները, համեմատվում են քսաներորդ դարասկզբին գործածված բժշկական ախտորոշիչ եզրույթները՝ ներկայիս գործածվող տարբերակների հետ։ Քննարկվում են նաև նրա ոտքի ոսկորի հիվանդությունն ու ֆիզիկական հյուծման պատճառով մահվան պարագան, ապա նաև թաղման կազմակերպումը։

Psychiatric disorders and offending in an Australian birth cohort: Overrepresentation in the health and criminal justice systems for Indigenous Australians

Objective: Most studies that examine psychiatric illness in people who offend have focused on incarcerated samples, with little known about the larger population of individuals with criminal justice system contact. We examine the overlap between proven offences and psychiatric diagnoses with an emphasis on experiences for Indigenous Australians. Methods: In a population-based birth cohort of 45,141 individuals born in Queensland, Australia, in 1990 (6.3% Indigenous), psychiatric diagnoses were identified from hospital admissions between ages 4/5 and 23/24 years and proven offences were identified from court records (spanning ages 10–24 years). Prevalence rates for offending, psychiatric diagnoses and their overlap were examined for Indigenous and non-Indigenous individuals. Associations between specific psychiatric diagnoses and types of offending were examined using logistic regressions. Results: There were 11,134 (24.7%) individuals with a finalised court appearance, 2937 (6.5%) with a diagnosed psychiatric disorder and 1556 (3.4%) with a proven offence and diagnosed psychiatric disorder, with Indigenous Australians significantly overrepresented across all outcomes. Compared with non-Indigenous Australians, Indigenous Australians were younger at their first court finalisation (Cohen’s d = −0.62, 95% confidence interval = [−0.67, −0.57]), experienced a higher number of finalisations ( d = 0.94, 95% confidence interval = [0.89, 1.00]) and offences ( d = 0.64, 95% confidence interval = [0.59, 0.69]) and were more likely to receive custodial ( d = 0.41, 95% confidence interval = [0.36, 0.46]) or supervised ( d = 0.55, 95% confidence interval = [0.50, 0.60]) sentences. The overlap between offending and psychiatric illness was more pronounced for Indigenous Australians compared with non-Indigenous Australians (14.8% vs 2.7%). Substance use disorders were the most prevalent psychiatric diagnosis among individuals with a court finalisation (9.2%). Conclusions: Indigenous Australians were significantly overrepresented in court finalisations and psychiatric diagnoses. Indigenous Australians with a psychiatric diagnosis were at highest risk of experiencing a court appearance, emphasising the importance of culturally appropriate mental health responses being embedded into the criminal justice system.

The demands of comorbidity: Implications for the explanation and classification of mental disorder

<p>A central goal of psychiatric classification is to assist in the assessment and treatment of those who experience mental disorder. This challenge takes on greater significance in complex cases, especially given the high prevalence of psychiatric comorbidity. High rates of comorbidity also challenge the validity of current psychiatric nosology. Etiological classification has been promoted as an alternative to improve the state of psychiatric diagnosis. However, comorbidity makes specific conceptual, explanatory and methodological demands of any such classification strategy. In this thesis, a demand for coherent and integrative explanation of comorbidity acts as a standard by which to assess the strength of different causal models of mental disorder and their resultant concepts. Integrative pluralism is presented as an epistemological framework well-suited to the complexity of this scientific challenge.</p>

The Psychiatric Misdiagnosis of Behavioral Variant Frontotemporal Dementia in a Colombian Sample

Objective: To describe the demographic characteristics, initial psychiatric diagnoses, and the time to reach a diagnosis of probable behavioral variant frontotemporal dementia (bvFTD) in a public psychiatric hospital in Cali, Colombia.Methods: We retrospectively reviewed the medical records of 28 patients who were diagnosed with probable bvFTD based on a multidisciplinary evaluation that included a structural MRI, neuropsychological testing, functional assessment, and neurological exam. Prior to this evaluation, all patients were evaluated by a psychiatrist as part of their initial consultation at the hospital. The initial consultation included the Neuropsychiatric Inventory and diagnoses based on the DSM-V. Demographics, clinical features, and initial psychiatric misdiagnoses were extracted from clinical records and summarized in the full sample and by gender.Results: The study sample had a mean education of 10.0 years (SD = 4.9) and 68.0% were female. In the full sample, 28.6% were initially diagnosed with dementia, and 71.4% with a psychiatric disorder. The psychiatric diagnosis at initial consultation differed by gender. Women were most likely to be diagnosed with depression (26.3%) or bipolar disorder (26.3%), while the men were most likely to be diagnosed with anxiety (33.3%) or a psychotic disorder (22.2%). Psychotic symptoms were common (delusions, 60.7% and hallucinations, 39.3%), and the pattern of neuropsychiatric symptoms did not differ by gender.Conclusions: This is one of few case series of bvFTD in a Colombian population, where bvFTD is a recognizable and prevalent disorder. In this psychiatric hospital, the majority of patients with bvFTD were initially diagnosed with a primary psychiatric condition. There was a gender difference in psychiatric diagnosis, but not in neuropsychiatric symptoms. In this sample, the rate of psychiatric misdiagnosis, as well as the psychotic symptoms, were higher compared to rates described in other countries. These results highlight the need for interventions to improve bvFTD diagnosis in under-represented populations.

The demands of comorbidity: Implications for the explanation and classification of mental disorder

<p>A central goal of psychiatric classification is to assist in the assessment and treatment of those who experience mental disorder. This challenge takes on greater significance in complex cases, especially given the high prevalence of psychiatric comorbidity. High rates of comorbidity also challenge the validity of current psychiatric nosology. Etiological classification has been promoted as an alternative to improve the state of psychiatric diagnosis. However, comorbidity makes specific conceptual, explanatory and methodological demands of any such classification strategy. In this thesis, a demand for coherent and integrative explanation of comorbidity acts as a standard by which to assess the strength of different causal models of mental disorder and their resultant concepts. Integrative pluralism is presented as an epistemological framework well-suited to the complexity of this scientific challenge.</p>

Assessment of psychiatric comorbidities and sociodemographic profiles of the patients referred to the general hospital psychiatric unit of a tertiary care hospital in Kolkata, West Bengal

Background: According to the previous studies, psychiatric symptoms are high in patients with physical illness, but the referral rates are much below expectation. Aims and Objectives: Here a descriptive cross-sectional study has been conducted using self designed semi structured proforma to asses the socio demographic profile and psychiatric diagnosis of patient with physical illness referred from other departments in a tertiary medical care centre for consultation liaison (C-L) psychiatry care. Materials and Methods: The study population consists of the patients referred to psychiatry department for consultation purpose from all the other departments in a 4 months period. The data were collected on a self designed semi structured pro forma and all the diagnosis were made according to International Classification of Disease -10 (ICD-10) criteria. Analysis has been done using descriptive statistics. Results: A total numbers of 203 patient has been referred to psychiatry department during the study period . Among them 144 were inpatient and 59 were outdoor based referral. Majority were female, married . The maximum referral were from general medicine department followed by neuromedicine. Most common reason of referral being suicidal attempt by different means followed by patients having depressive features .The most common psychiatric diagnosis was depression followed by delirium. Conclusion: C-L psychiatry plays a significant role in better evaluation and management of patients with psychiatric comorbidities referred from non-psychiatric departments.