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Admission to an inpatient psychiatry unit or a medical unit? Consider 3 Ms and 3 Ps
Hospital psychiatrists often are asked whether a patient with comorbid medical and psychiatric illnesses should be admitted to an inpatient psychiatry unit or to a medical unit. Psychiatric units vary widely in their capacity to manage patients’ medical conditions. Medical comorbidity also is associated with longer psychiatric hospitalizations.1 The decision of where to admit may be particularly challenging when presented with a patient with delirium, which often mimics primary psychiatric illnesses such as depression but will not resolve without treatment of the underlying illness. While diagnosis and treatment of delirium typically occur in the hospital setting, 1 study found that approximately 15% of 199 psychiatric inpatients were delirious and that these patients had hospital stays that were approximately 62% longer than those without delirium.2
When you need to determine whether a patient should be admitted to an inpatient psychiatry unit with a medical consult or vice versa, consider the following 3 Ms and 3 Ps.
Medications. Can medications, including those that are given intravenously or require serum monitoring, be administered on the psychiatric unit? Can the medical unit administer involuntary psychotropics?
Mobility. Does the patient require assistance with mobility? Does the patient pose a fall risk? A physical therapy consult may be helpful.
Monitoring. Suicide risk is the most common indication for patient sitters.3 Would a patient sitter be needed for the patient? On the other hand, can the psychiatry unit manage telemetry, frequent vital signs, or infectious disease precautions?
People. Would the patient benefit from the therapeutic milieu and specialized staff of an inpatient psychiatry unit?
Prognosis. What ongoing medical and psychiatric management is required? What are the medical and psychiatric prognoses?
Placement. To where will the patient be transferred after hospitalization? How does admission to inpatient psychiatry vs medical impact the ultimate disposition?
Help the treatment team make the decision
Determining the ideal patient placement often evokes strong feelings among treatment teams. Psychiatrists can help facilitate the conversation by asking the questions outlined above, and by keeping in mind, “What is best for this patient?”
1. Rodrigues-Silva N, Ribeiro L. Impact of medical comorbidity in psychiatric inpatient length of stay. J Ment Health. 2017:1-5 [epub ahead of print].
2. Ritchie J, Steiner W, Abrahamowicz M. Incidence of and risk factors for delirium among psychiatric inpatients. Psychiatr Serv. 1996;47(7):727-730.
3. Solimine S, Takeshita J, Goebert D, et al. Characteristics of patients with constant observers. Psychosomatics. 2018;59(1):67-74.
Hospital psychiatrists often are asked whether a patient with comorbid medical and psychiatric illnesses should be admitted to an inpatient psychiatry unit or to a medical unit. Psychiatric units vary widely in their capacity to manage patients’ medical conditions. Medical comorbidity also is associated with longer psychiatric hospitalizations.1 The decision of where to admit may be particularly challenging when presented with a patient with delirium, which often mimics primary psychiatric illnesses such as depression but will not resolve without treatment of the underlying illness. While diagnosis and treatment of delirium typically occur in the hospital setting, 1 study found that approximately 15% of 199 psychiatric inpatients were delirious and that these patients had hospital stays that were approximately 62% longer than those without delirium.2
When you need to determine whether a patient should be admitted to an inpatient psychiatry unit with a medical consult or vice versa, consider the following 3 Ms and 3 Ps.
Medications. Can medications, including those that are given intravenously or require serum monitoring, be administered on the psychiatric unit? Can the medical unit administer involuntary psychotropics?
Mobility. Does the patient require assistance with mobility? Does the patient pose a fall risk? A physical therapy consult may be helpful.
Monitoring. Suicide risk is the most common indication for patient sitters.3 Would a patient sitter be needed for the patient? On the other hand, can the psychiatry unit manage telemetry, frequent vital signs, or infectious disease precautions?
People. Would the patient benefit from the therapeutic milieu and specialized staff of an inpatient psychiatry unit?
Prognosis. What ongoing medical and psychiatric management is required? What are the medical and psychiatric prognoses?
Placement. To where will the patient be transferred after hospitalization? How does admission to inpatient psychiatry vs medical impact the ultimate disposition?
Help the treatment team make the decision
Determining the ideal patient placement often evokes strong feelings among treatment teams. Psychiatrists can help facilitate the conversation by asking the questions outlined above, and by keeping in mind, “What is best for this patient?”
Hospital psychiatrists often are asked whether a patient with comorbid medical and psychiatric illnesses should be admitted to an inpatient psychiatry unit or to a medical unit. Psychiatric units vary widely in their capacity to manage patients’ medical conditions. Medical comorbidity also is associated with longer psychiatric hospitalizations.1 The decision of where to admit may be particularly challenging when presented with a patient with delirium, which often mimics primary psychiatric illnesses such as depression but will not resolve without treatment of the underlying illness. While diagnosis and treatment of delirium typically occur in the hospital setting, 1 study found that approximately 15% of 199 psychiatric inpatients were delirious and that these patients had hospital stays that were approximately 62% longer than those without delirium.2
When you need to determine whether a patient should be admitted to an inpatient psychiatry unit with a medical consult or vice versa, consider the following 3 Ms and 3 Ps.
Medications. Can medications, including those that are given intravenously or require serum monitoring, be administered on the psychiatric unit? Can the medical unit administer involuntary psychotropics?
Mobility. Does the patient require assistance with mobility? Does the patient pose a fall risk? A physical therapy consult may be helpful.
Monitoring. Suicide risk is the most common indication for patient sitters.3 Would a patient sitter be needed for the patient? On the other hand, can the psychiatry unit manage telemetry, frequent vital signs, or infectious disease precautions?
People. Would the patient benefit from the therapeutic milieu and specialized staff of an inpatient psychiatry unit?
Prognosis. What ongoing medical and psychiatric management is required? What are the medical and psychiatric prognoses?
Placement. To where will the patient be transferred after hospitalization? How does admission to inpatient psychiatry vs medical impact the ultimate disposition?
Help the treatment team make the decision
Determining the ideal patient placement often evokes strong feelings among treatment teams. Psychiatrists can help facilitate the conversation by asking the questions outlined above, and by keeping in mind, “What is best for this patient?”
1. Rodrigues-Silva N, Ribeiro L. Impact of medical comorbidity in psychiatric inpatient length of stay. J Ment Health. 2017:1-5 [epub ahead of print].
2. Ritchie J, Steiner W, Abrahamowicz M. Incidence of and risk factors for delirium among psychiatric inpatients. Psychiatr Serv. 1996;47(7):727-730.
3. Solimine S, Takeshita J, Goebert D, et al. Characteristics of patients with constant observers. Psychosomatics. 2018;59(1):67-74.
1. Rodrigues-Silva N, Ribeiro L. Impact of medical comorbidity in psychiatric inpatient length of stay. J Ment Health. 2017:1-5 [epub ahead of print].
2. Ritchie J, Steiner W, Abrahamowicz M. Incidence of and risk factors for delirium among psychiatric inpatients. Psychiatr Serv. 1996;47(7):727-730.
3. Solimine S, Takeshita J, Goebert D, et al. Characteristics of patients with constant observers. Psychosomatics. 2018;59(1):67-74.
When to use an anticonvulsant to treat alcohol withdrawal
Alcohol withdrawal is an uncomfortable and potentially life-threatening condition that must be treated before patients can achieve sobriety. Benzodiazepines remain the first-line treatment for alcohol withdrawal; however, these agents could:
- exacerbate agitation
- interact adversely with other medications, particularly opioids
- be unsafe for outpatients at risk of drinking again.
Off-label use of anticonvulsants could reduce these risks. In our emergency department, we routinely use these agents as monotherapy for patients discharging to outpatient detoxification or as adjunctive treatment for patients who require admission for severe withdrawal (Table1,2).
Gabapentin is safe for patients with liver disease and has few drug–drug interactions.1 Dosages of at least 1,200 mg/d seems to be comparable to lorazepam for alcohol withdrawal and could help prevent relapse after the withdrawal period.1 Many patients report that gabapentin helps them sleep. Gabapentin could cause gastrointestinal upset or slight dizziness; patients with severe renal disease might require dosage adjustments.
Carbamazepine. In a randomized double-blind trial, carbamazepine was superior to lorazepam in preventing rebound withdrawal symptoms and reducing post-treatment drinking, although both agents were effective in decreasing withdrawal symptoms.2 Avoid this agent in patients with serum liver enzymes 3 times higher than normal values
Divalproex with as-needed benzodiazepines reduces the duration of withdrawal and risk of medical complications.3 Avoid using divalproex in patients with thrombocytopenia, leukopenia, or severe liver disease.
1. Myrick H, Malcolm R, Randall PK, et al. A double-blind trial of gabapentin versus lorazepam in the treatment of alcohol withdrawal. Alcohol Clin Exp Res. 2009;33(9):1582-1588.
2. Malcom R, Myrick H, Roberts J, et al. The effects of carbamazepine and lorazepam on a single versus multiple previous alcohol withdrawals in an outpatient randomized trial. J Gen Int Med. 2002;17(5):349-355.
3. Eyer F, Schreckenberg M, Adorjan K, et al. Carbamazepine and valproate as adjuncts in the treatment of alcohol withdrawal syndrome: a retrospective cohort study. Alcohol Alcohol. 2011;46(2):177-184.
Alcohol withdrawal is an uncomfortable and potentially life-threatening condition that must be treated before patients can achieve sobriety. Benzodiazepines remain the first-line treatment for alcohol withdrawal; however, these agents could:
- exacerbate agitation
- interact adversely with other medications, particularly opioids
- be unsafe for outpatients at risk of drinking again.
Off-label use of anticonvulsants could reduce these risks. In our emergency department, we routinely use these agents as monotherapy for patients discharging to outpatient detoxification or as adjunctive treatment for patients who require admission for severe withdrawal (Table1,2).
Gabapentin is safe for patients with liver disease and has few drug–drug interactions.1 Dosages of at least 1,200 mg/d seems to be comparable to lorazepam for alcohol withdrawal and could help prevent relapse after the withdrawal period.1 Many patients report that gabapentin helps them sleep. Gabapentin could cause gastrointestinal upset or slight dizziness; patients with severe renal disease might require dosage adjustments.
Carbamazepine. In a randomized double-blind trial, carbamazepine was superior to lorazepam in preventing rebound withdrawal symptoms and reducing post-treatment drinking, although both agents were effective in decreasing withdrawal symptoms.2 Avoid this agent in patients with serum liver enzymes 3 times higher than normal values
Divalproex with as-needed benzodiazepines reduces the duration of withdrawal and risk of medical complications.3 Avoid using divalproex in patients with thrombocytopenia, leukopenia, or severe liver disease.
Alcohol withdrawal is an uncomfortable and potentially life-threatening condition that must be treated before patients can achieve sobriety. Benzodiazepines remain the first-line treatment for alcohol withdrawal; however, these agents could:
- exacerbate agitation
- interact adversely with other medications, particularly opioids
- be unsafe for outpatients at risk of drinking again.
Off-label use of anticonvulsants could reduce these risks. In our emergency department, we routinely use these agents as monotherapy for patients discharging to outpatient detoxification or as adjunctive treatment for patients who require admission for severe withdrawal (Table1,2).
Gabapentin is safe for patients with liver disease and has few drug–drug interactions.1 Dosages of at least 1,200 mg/d seems to be comparable to lorazepam for alcohol withdrawal and could help prevent relapse after the withdrawal period.1 Many patients report that gabapentin helps them sleep. Gabapentin could cause gastrointestinal upset or slight dizziness; patients with severe renal disease might require dosage adjustments.
Carbamazepine. In a randomized double-blind trial, carbamazepine was superior to lorazepam in preventing rebound withdrawal symptoms and reducing post-treatment drinking, although both agents were effective in decreasing withdrawal symptoms.2 Avoid this agent in patients with serum liver enzymes 3 times higher than normal values
Divalproex with as-needed benzodiazepines reduces the duration of withdrawal and risk of medical complications.3 Avoid using divalproex in patients with thrombocytopenia, leukopenia, or severe liver disease.
1. Myrick H, Malcolm R, Randall PK, et al. A double-blind trial of gabapentin versus lorazepam in the treatment of alcohol withdrawal. Alcohol Clin Exp Res. 2009;33(9):1582-1588.
2. Malcom R, Myrick H, Roberts J, et al. The effects of carbamazepine and lorazepam on a single versus multiple previous alcohol withdrawals in an outpatient randomized trial. J Gen Int Med. 2002;17(5):349-355.
3. Eyer F, Schreckenberg M, Adorjan K, et al. Carbamazepine and valproate as adjuncts in the treatment of alcohol withdrawal syndrome: a retrospective cohort study. Alcohol Alcohol. 2011;46(2):177-184.
1. Myrick H, Malcolm R, Randall PK, et al. A double-blind trial of gabapentin versus lorazepam in the treatment of alcohol withdrawal. Alcohol Clin Exp Res. 2009;33(9):1582-1588.
2. Malcom R, Myrick H, Roberts J, et al. The effects of carbamazepine and lorazepam on a single versus multiple previous alcohol withdrawals in an outpatient randomized trial. J Gen Int Med. 2002;17(5):349-355.
3. Eyer F, Schreckenberg M, Adorjan K, et al. Carbamazepine and valproate as adjuncts in the treatment of alcohol withdrawal syndrome: a retrospective cohort study. Alcohol Alcohol. 2011;46(2):177-184.
Treating a patient who has ‘everything’
Patients who endorse multiple psychiatric symptoms and meet criteria for several DSM diagnoses pose diagnostic and therapeutic challenges. In community samples, approximately 40% of patients with a DSM diagnosis have >1 illness, and comorbidity is more frequent in clinical trials.1 We highlight things to consider when managing a patient who has “everything.”
Endorsing ‘everything’ means something in itself. Patients with borderline personality disorder often present with myriad, disparate diagnoses and urgent requests for care.2 Also consider primary or secondary gain, particularly if the patient’s descriptions of symptoms are unusual. Saying “yes” to every question or endorsing highly unusual symptoms described by the interviewer may represent suggestibility related to catatonia or confabulation.
Focus on the most impairing symptom. This may help put other symptoms in context and focus treatment.
Find a common goal. If you can’t pick a simple symptom, move on to helping the patient identify his or her goals by asking questions such as, “Four weeks from now, what would you like to be doing?” Picking an achievable, measurable goal may be therapeutic.
Are the symptoms valid? Examine individual symptoms for validity using the SAFER criteria (Table).3
Table
SAFER criteria for symptom validity
| State vs trait: has the symptom lasted <12 weeks? |
| Assessable: can the symptom be measured? |
| Face validity: does the symptom clearly affect the patient’s behavior and functioning? |
| Ecological validity: is the symptom valid with our knowledge of its occurrence? |
| Rule of the 3Ps: is the symptom Persistent; Pathologically disruptive and different than usual; and Pervasive across normal domains? |
| Source: Reference 3 |
Multiple diagnoses may be in play, but start by treating one. Many patients meet criteria for multiple diagnoses. There is little evidence about which diagnosis should be treated first. Use your judgment in picking “the best first step” and treat accordingly.
Resist polypharmacy. Target specific symptoms or goals until a clear diagnostic picture emerges.
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-627.
2. Gunderson JG. Borderline personality disorder: ontogeny of a diagnosis. Am J Psychiatry. 2009;166(5):530-539.
3. Targum SD, Pollack MH, Fava M. Redefining affective disorders: relevance for drug development. CNS Neurosci Ther. 2008;14(1):2-9.
Patients who endorse multiple psychiatric symptoms and meet criteria for several DSM diagnoses pose diagnostic and therapeutic challenges. In community samples, approximately 40% of patients with a DSM diagnosis have >1 illness, and comorbidity is more frequent in clinical trials.1 We highlight things to consider when managing a patient who has “everything.”
Endorsing ‘everything’ means something in itself. Patients with borderline personality disorder often present with myriad, disparate diagnoses and urgent requests for care.2 Also consider primary or secondary gain, particularly if the patient’s descriptions of symptoms are unusual. Saying “yes” to every question or endorsing highly unusual symptoms described by the interviewer may represent suggestibility related to catatonia or confabulation.
Focus on the most impairing symptom. This may help put other symptoms in context and focus treatment.
Find a common goal. If you can’t pick a simple symptom, move on to helping the patient identify his or her goals by asking questions such as, “Four weeks from now, what would you like to be doing?” Picking an achievable, measurable goal may be therapeutic.
Are the symptoms valid? Examine individual symptoms for validity using the SAFER criteria (Table).3
Table
SAFER criteria for symptom validity
| State vs trait: has the symptom lasted <12 weeks? |
| Assessable: can the symptom be measured? |
| Face validity: does the symptom clearly affect the patient’s behavior and functioning? |
| Ecological validity: is the symptom valid with our knowledge of its occurrence? |
| Rule of the 3Ps: is the symptom Persistent; Pathologically disruptive and different than usual; and Pervasive across normal domains? |
| Source: Reference 3 |
Multiple diagnoses may be in play, but start by treating one. Many patients meet criteria for multiple diagnoses. There is little evidence about which diagnosis should be treated first. Use your judgment in picking “the best first step” and treat accordingly.
Resist polypharmacy. Target specific symptoms or goals until a clear diagnostic picture emerges.
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Patients who endorse multiple psychiatric symptoms and meet criteria for several DSM diagnoses pose diagnostic and therapeutic challenges. In community samples, approximately 40% of patients with a DSM diagnosis have >1 illness, and comorbidity is more frequent in clinical trials.1 We highlight things to consider when managing a patient who has “everything.”
Endorsing ‘everything’ means something in itself. Patients with borderline personality disorder often present with myriad, disparate diagnoses and urgent requests for care.2 Also consider primary or secondary gain, particularly if the patient’s descriptions of symptoms are unusual. Saying “yes” to every question or endorsing highly unusual symptoms described by the interviewer may represent suggestibility related to catatonia or confabulation.
Focus on the most impairing symptom. This may help put other symptoms in context and focus treatment.
Find a common goal. If you can’t pick a simple symptom, move on to helping the patient identify his or her goals by asking questions such as, “Four weeks from now, what would you like to be doing?” Picking an achievable, measurable goal may be therapeutic.
Are the symptoms valid? Examine individual symptoms for validity using the SAFER criteria (Table).3
Table
SAFER criteria for symptom validity
| State vs trait: has the symptom lasted <12 weeks? |
| Assessable: can the symptom be measured? |
| Face validity: does the symptom clearly affect the patient’s behavior and functioning? |
| Ecological validity: is the symptom valid with our knowledge of its occurrence? |
| Rule of the 3Ps: is the symptom Persistent; Pathologically disruptive and different than usual; and Pervasive across normal domains? |
| Source: Reference 3 |
Multiple diagnoses may be in play, but start by treating one. Many patients meet criteria for multiple diagnoses. There is little evidence about which diagnosis should be treated first. Use your judgment in picking “the best first step” and treat accordingly.
Resist polypharmacy. Target specific symptoms or goals until a clear diagnostic picture emerges.
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-627.
2. Gunderson JG. Borderline personality disorder: ontogeny of a diagnosis. Am J Psychiatry. 2009;166(5):530-539.
3. Targum SD, Pollack MH, Fava M. Redefining affective disorders: relevance for drug development. CNS Neurosci Ther. 2008;14(1):2-9.
1. Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-627.
2. Gunderson JG. Borderline personality disorder: ontogeny of a diagnosis. Am J Psychiatry. 2009;166(5):530-539.
3. Targum SD, Pollack MH, Fava M. Redefining affective disorders: relevance for drug development. CNS Neurosci Ther. 2008;14(1):2-9.