Consultation-liaison approach for the management of psychiatric manifestations in inpatients of neurology and neurosurgery wards
Nimmi Jose, Deeksha Elwadhi, Deepika Makkar
Department of Psychiatry, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research (GIPMER), New Delhi, India
Background: Psychiatric manifestations in patients admitted in neurology and neurosurgery wards are now being increasingly recognized as important causes of morbidity and mortality.
Materials and method: We studied the psychiatric manifestations for referral (N = 46) to consultation-liaison psychiatry services from neurology/neurosurgery between January 2016 and March 2016 using structured clinical proforma.
Results: Space occupying lesions were the most common neurological diagnosis (30%). The most common reason for referral was delirium (20%), followed by dissociative disorders (17%) and psychosis (15%).
Conclusions: Psychiatric co morbidity is high among in-patients with space occupying lesions, epilepsy and movement disorders are common. Timely assessment using structured clinical proforma would help in enhanced detection of delirium and other psychiatric co morbidities.
Keywords: Neurosurgery, Psychiatric illness, Neuro-imaging.
Psychiatric disorders (PDs) in neurology are more frequent than it is verified in routine exam, not only in the less developed but also in large and very developed neurological/neurosurgical departments1 .They are now being increasingly recognized as important causes of morbidity and mortality. The presence of psychiatric co morbidity affects the quality-of-life of patients in a significant way.
They also contribute to the distress of caregivers. Early detection and treatment of mental symptoms is of paramount importance. To achieve this objective, it is necessary that the treating neurologist/ neurosurgeon recognizes the psychiatric symptoms at an early stage and makes a referral to the psychiatry services. It would be ideal to have a consultation-liaison team, which looks specifically into the psychiatry needs of patients with neurological conditions. In this report, we have examined the psychiatric manifestations in patients who were referred to consultation-liaison psychiatry (CLP) services from neurology and neurosurgery wards.
MATERIAL AND METHODS
Govind Ballabh Pant Institute of Post graduate Medical Education and Research (GIPMER), New Delhi, India, is a leading super speciality tertiary care hospital for patient care and an institute for academic pursuit in various branches like cardiology, cardio thoracic surgery, neurology, neurosurgery, gastroenterology, gastro surgery, psychiatry and radiology. GIPMER has 714 inpatient beds with daily outpatient turnover of more than 800 patients. A dedicated consultation-liaison psychiatry (CLP) services is available for admitted patients of all departments. The team is composed of psychiatry consultants, senior residents and junior residents (by rotation). One junior resident and one senior resident, who is a trained MD Psychiatry degree holder, are posted on consultation-liaison duty each day.
Each patient referred to CLP service is evaluated in detail by the duty resident using the CLP work-up proforma. All patients are seen within 24 h of receiving the call for a consultation. The residents are routinely trained to evaluate referred patients by senior consultants of the CLP service. The CLP work-up proforma includes socio-demographic data, neurological diagnosis, neurological treatment given, reasons for psychiatry referral, brief history of presenting illness, past history of psychiatric illness, family history of medical/psychiatric illness, personal history, pre-morbid personality, mental status examination, cognitive function tests (including mini mental status examination), investigations (blood and urine investigations, radiology, electroencephalogram, electrocardiogram, cerebrospinal fluid examination), provisional psychiatric diagnosis and management plan (pharmacological and psychosocial). The diagnosis of psychiatric condition is made according to the International Classification of Diseases, version-10 criteria. 2 Sub-syndromal symptoms are also recorded.
Record is regularly maintained of all the referrals and is discussed with and signed by the senior consultant of the CLP team. All consecutive in-patients who were referred to the specialty CLP services during the period from January 2016 to March 2016 at the GIPMER, New Delhi, India formed the sample of this study. Statistical analyses were performed using the SPSS version 20 (SPSS, Chicago, IL, USA. The entire process was a part of routine clinical assessment and hence no separate consent was obtained. The data was accessed from the case records of patients and study does not reveal patient identity in any manner.
During the above period, a total of 46 patients from neurology and neurosurgery wards were referred for psychiatric consultation as the primary treating team suspected of psychiatric co morbidity. The mean age was 30.1 ± 16.3 years, 24 (52%) were men, 22 (48%) were women. The most common reason for referral was for assessment of behavioral problems (n = 9, 20%) [Table 2]. 11% did not have symptoms amounting t any psychiatric diagnosis. Out of the 46 patients who were referred, 14 (30%) had the diagnosis of space occupying lesions, 10 (22%) had epilepsy and 7 (15%) had movement disorders and constituted the largest majority. The rest of patients had diverse neurological diagnosis [Table 1]
Table 1: Neurological diagnosis of referred cases
|Neurological diagnosis||N (%)|
|Space occupying lesions||14 (30)
|Intra cranial bleed
|Facial nerve palsy||1 (2)
Psychiatric manifestations were prevalent in 41 patients (89%) out of 46 patients. Amongst patients who had space occupying lesions, 6 (43%) had delirium 3 (24%) had psychosis and 2 (14%) had anxiety symptoms. In patients with epilepsy, 4 (40%) had psychosis, and 2 (20%) had mental retardation.
Table 2: Psychiatric diagnosis after evaluation by the consultation liaison psychiatry team.
|Psychiatric diagnosis||N (%)|
|Dissociative disorder||8 (17)|
|Mental retardation with behavioral||3 (6.5)|
|Post head injury sequel||1 (2)|
|Obsessive compulsive disorder||1 (2)|
|Deliberate self harm||5 (11)|
We observed that more number of consultation-liaison psychiatry (CLP) services were sought from neurology (n=32, 70%) as compared to neurosurgery (n=14, 30%). Out of all the referrals, 41 (89%) cases could be diagnosed with psychiatric conditions based on ICD-10. The maximum number of cases were of delirium (n=9, 20%) out of which 7 (78%) were referred to us from the neurosurgery ward. And most of the cases of delirium were noted in patients with space occupying lesions/SOL (n=7, 78%). Psychosis was reported in 7 (15%) cases, of which 3 (43%) was seen in patients with space occupying lesions, 3(43%) in patients with neuro-infection. It is important for clinicians to have an index of suspicion of SOL in patients with new-onset psychiatric symptoms, atypical presentations and treatment resistance and, as a result, consider neuro-imaging. Early detection is of paramount importance for treatment and quality of life of patients3.
Also, some patients with neurologically silent brain tumors may present with psychiatric symptoms only. Therefore, we emphasize the consideration of neuro-imaging in patients with a change in mental status regardless of a lack of neurological symptoms 4 5. 1 (14%) patient was diagnosed with psychosis following head injury. In a cross sectional study with a sample size of 361, the number in the head injury group who were diagnosed with schizophrenia was 3.4% 6. This difference in percentage can be attributed to the small sample size of our study. Dissociative disorder was diagnosed in 8 (17.2%) of cases of which 3 (37.5%) had been diagnosed as seizure disorder. This percentage is slightly more than that quoted in previous studies, possibly because f the small sample size and duration of our study In previous studies 20% to 30% of patients referred to an epilepsy center for refractory epilepsy received the diagnosis of dissociative seizures7.
There is an average delay of seven years before dissociative seizures are correctly diagnosed.8 The potential complications of such diagnostic delays include the adverse effects of antiepileptic medications, iatrogenic complications (e.g., vocal-cord injury during intubation or pneumothorax during central venous catheterization when the patient is in status pseudoepilepticus),9 the costs of unnecessary hospitalization and absence from work, delayed referral for psychotherapy, and other problems and limitations, both at work and at home.10 This shows that a careful scrutiny of clinical history as well as relevant investigations is required in cases specially presenting as seizures as there can be only subtle pointers against organicity.
A meticulous history taking and relevant investigations can spare a patient of unnecessary exposure to anticonvulsants. It also calls for a close coordination between the neurologist and psychiatrist. Proper communication of the diagnosis has been reported to lower the frequency of seizures by more than half and to lessen the patient’s utilization of health-care resources. 11 Intermediate steps are needed, based on collaboration of the neurologist and psychiatrist. Proper communication of the diagnosis can ease the patient’s acceptance of psychiatric intervention. 12
Our study shows that psychiatric co morbidity was high in admitted patients with space occupying lesions and delirium was the most common co morbidity. Few cases initially diagnosed as epilepsy and movement disorder were eventually diagnosed as dissociative disorders. Consultation-liaison services help in increasing the quality of patient care in neurology and neurosurgery patients.
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- WHO. The ICD-10 Classification of Mental and Behavioral Disorders: Clinical Description and Diagnostic Guidelines. Geneva: World Health Organization; 1992.
- Madhusoodanan S, Danan D, Moise D. Psychiatric manifestations of brain tumors: diagnostic implications. Expert Rev Neurother 2007; Apr;7(4):343-9.
- Madhusoodanan S, Danan D, Brenner R, Bogunovic O. Brain tumor and psychiatric manifestations: a case report and brief review. Ann Clin Psychiatry 2004; Apr-Jun;16(2):111-3.
- Moise D1, Madhusoodanan S. Psychiatric symptoms associated with brain tumors: a clinical enigma. CNS Spectr 2006; Jan;11(1):28-31.
- Silver JM, Kramer R, Greenwald S, Weissman M. The association between head injuries and psychiatric disorders: findings from the New York NIMH epidemiologic catchment area study. Brain Injury 2001;15:935–45.
- Benbadis SR. The EEG in nonepileptic seizures .J Clin Neurophysiol. 2006; Aug;23(4):340-52.
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