Establishment and preliminary evaluation of a teaching hospital-based dementia consultation service for rurally-based regional district general hospitals

The treatment of patients with dementia poses a considerable challenge to regional district general hospitals, particularly in rural areas. Here we report the establishment and initial evaluation of a dementia-specific consultation service provided by a teaching hospital-based Psychiatry Department to regional district general hospitals in smaller surrounding towns. The service was provided to patients both with pre-existing and newly diagnosed or suspected dementia, who were in acute hospital care for concurrent conditions. An initial evaluation of 61 consultations - 49 on-site and 12 via telemedicine - was performed to assess the needs of the participating hospitals and the specific nature of the referrals to the consultation service. Suspected dementia or cognitive dysfunction was the primary reason for consultation requests (>50% of cases). Other common requests concerned suspected delirium, behavioral disturbances, and therapeutic recommendations. During the consultations, a diagnosis of dementia was reached in 52.5% of cases, with other common diagnoses including delirium and depression. Recommendations related to pharmacotherapy were given in 54.1% of consultations. Other recommendations included referral for outpatient neurological or psychiatric follow-up, further diagnostic assessment, or assessment in a memory clinic. Geriatric psychiatric inpatient treatment was recommended in only seven cases (11.5 %). Our initial evaluation demonstrates the feasibility of providing a dementia-specific consultation service in a rural area. The service has the potential to reduce acute transfers to inpatient geriatric psychiatry and enables older patients with dementia or delirium to be treated locally by helping and empowering rurally-based regional hospitals to manage these problems and associated complications.

A case of pervasive refusal syndrome related to COVID19

ObjectiveTo highlight the importance of appropriate diagnosis and management of severe mental illness in children. Awareness of rare diagnoses such as this will reduce the delay to treatment. A challenge in Ireland is accessing psychiatric inpatient treatment for very young children, with specialist units in Ireland designed to better cater for young people aged 12+.Case reportMichael (not his real name), age 10, was always described as a happy, calm child. He enjoyed school and loved playing outdoors. He had been progressing well with his life and neither his parents nor school had any concerns for him. Following the COVID-19 pandemic and school closures, Michael began to became more conscious of daily hygiene safety advice. However, things escalated to a very difficult level. Initially, he manifested extreme levels of anxiety with heightened levels of distress. He ran away from open doors or windows for fear he would catch the virus, insisted on changing his clothes several times per day, would become distressed if anyone touched him accidentally while he was outside and could spend hours afterwards crying and screaming.In June 2020 he showed profound refusal to engage in basic care tasks and a dramatic social withdrawal, and ultimately required admission to hospital. He refused to eat and drink, stopped washing and toileting himself, lay in bed with the covers over this head, became non-verbal and refused to engage with any conversation or games. He showed prolonged periods of screaming. Ultimately this reached a level requiring TPN and PEG feeding and a low stimulation environment. Diagnosis of pervasive refusal disorder, secondary to severe COVID-19 related anxiety was made.DiscussionPervasive refusal disorder is a rare and potentially life threatening condition in children. It is described as a profound psychological response to uncontrollable events such as grief, abuse, parental conflict and migration. In this case, it was the threat of the global pandemic. Through treatment in low stimulation environments, with consistent communication and rehabilitation and medication, followed by individual and family therapies when patients are more able, patients show a slow, but generally complete recovery. Happily for Michael, he has now recovered and returned home to his family, where he has returned to all his previous activities.ConclusionMichael and his parents have kindly agreed to allow us to tell his story, in the hope of teaching current and future psychiatrists about this rare condition. We send them our thanks and appreciation.

Self-admission in the treatment of eating disorders: an analysis of healthcare resource reallocation

Background Self-admission to psychiatric inpatient treatment is an innovative approach to healthcare rationing, based on reallocation of existing resources rather than on increased funding. In self-admission, patients with a history of high healthcare utilization are invited to decide for themselves when brief admission is warranted. Previous findings on patients with severe eating disorders indicate that self-admission reduces participants’ need for inpatient treatment, but that it does not alone lead to symptom remission. Methods The aim of this study was to evaluate if, from a service provider perspective, the resource reallocation associated with self-admission is justified. The analysis makes use of data from a cohort study evaluating the one-year outcomes of self-admission at the Stockholm Centre for Eating Disorders. Results Participants in the program reduced their need for regular specialist inpatient treatment by 67%. Thereby, hospital beds were made available for non-participants due to the removal of a yearly average of 13.2 high-utilizers from the regular waiting list. A sensitivity analysis showed that this “win-win situation” occurred within the entire 95% confidence interval of the inpatient treatment utilization reduction. Conclusions For healthcare systems relying on rationing by waiting list, self-admission has the potential to reduce the need for hospitalization for patients with longstanding eating disorders, while also offering benefits in the form of increased available resources for other patients requiring hospitalization. Trial Registration ClinicalTrials.gov ID: NCT02937259 (retrospectively registered 10/15/2016).

Different needs in patients with schizophrenia spectrum disorders who behave aggressively towards others depend on gender: a latent class analysis approach

Background There is limited research with inconsistent findings on differences between female and male offender patients with a schizophrenia spectrum disorder (SSD), who behave aggressively towards others. This study aimed to analyse inhomogeneities in the dataset and to explore, if gender can account for those. Methods Latent class analysis was used to analyse a mixed forensic dataset consisting of 31 female and 329 male offender patients with SSD, who were accused or convicted of a criminal offence and were admitted to forensic psychiatric inpatient treatment between 1982 and 2016 in Switzerland. Results Two homogenous subgroups were identified among SSD symptoms and offence characteristics in forensic SSD patients that can be attributed to gender. Despite an overall less severe criminal and medical history, the female-dominated class was more likely to receive longer prison terms, similarly high antipsychotic dosages, and was less likely to benefit from inpatient treatment. Earlier findings were confirmed and extended in terms of socio-demographic variables, diseases and criminal history, comorbidities (including substance use), the types of offences committed in the past and as index offence, accountability assumed in court, punishment adjudicated, antipsychotic treatment received, and the development of symptoms during psychiatric inpatient treatment. Conclusions Female offender patients with schizophrenia might need a more tailored approach in prevention, assessment and treatment to diminish tendencies of inequity shown in this study.

Role of involvement in bullying as predictor for hospital-treated assault exposures among former adolescent psychiatric inpatients

Objective Bullying is a common problem among children and adolescents. Previous studies have investigated the associations between involvement in bullying and various psychosocial and mental health outcomes thoroughly. However, only few studies have focused on the association between bullying and exposure to assaults. This study investigated whether the likelihood for severe assault exposure varies among three subgroups of bullying behavior: bullies/bully-victims, victims of bullying, and those not involved in bullying. Method The study population consisted of 508 adolescents (208 boys, 300 girls) aged between 13 and 17 years (mean age 15.5 years), admitted for psychiatric inpatient treatment between the years 2001–2006. Adolescents were interviewed at index hospitalization using semi-structured interview, K-SADS-PL, to assess DSM-IV based adolescent psychiatric disorders, and to obtain information on bullying behavior. Treatment episodes for assault incidents were obtained from the Finnish National Care Register for Health Care covering the entire-life of the study participants up to end of year 2016. Results 14.4% (n = 73) of the study participants had experienced severe physical or sexual assault leading to hospital treatment during their lifetime. Results of Cox regression analysis showed that girl bullies/bully-victims had nearly threefold increased likelihood for later assault exposure. Conclusions Since bullying behavior in childhood and adolescence is a significant predictor for later exposure to severe assault in girls, it should be paid attention to and intervened as early as possible. Moreover, psychosocial risk factors should be taken into account considering those in hospital treatment for severe assault exposure.

Evolution of Clinical Outcome During Adolescents’ Psychiatric Inpatient Care: A Prospective Multiple Informant Study

Background: Examining the effectiveness and adequacy of adolescents’ psychiatric inpatient treatment through multiple perspectives is crucial to provide the best care. Objectives: The aims of the current study were to examine the consistencies and discrepancies between patients and clinicians and to understand how each group considered the timing of improvement of symptoms and psychosocial difficulties of adolescents during a psychiatric inpatient stay. Methods: The Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA, assessing symptoms and psychosocial difficulties) was rated on a weekly basis by patients and clinicians during a psychiatric inpatient stay. Data were collected from 297 patients, 58.2% females. Results: Both clinicians and patients reported a significant decrease of the HoNOSCA scores from admission to discharge, revealing that inpatient treatment is perceived as helping the adolescents to alleviate their symptoms and psychosocial difficulties. However, the item-by-item analyses indicated that patients and clinicians reported difficulties in different symptoms and psychosocial domains. Moreover, the week-by-week analyses revealed discrepancies in the perception of the time-course of clinical outcome-changes between clinicians and patients, as well as between males and females, and between voluntarily and involuntarily admitted patients. Conclusions: By integrating perspectives of patients and clinicians and their respective timelines, as well as by taking into account the mode of admission and the patient’s gender, this study provides a deeper understanding of the evolution of clinical outcome during adolescents’ hospitalizations, which allows to adapt their treatment and therewith, to help patients more efficiently.