Scuola di Medicina
Corso di Laurea Magistrale in Medicina e Chirurgia
Tesi di Laurea Magistrale
Characteristics of Psychiatric Disorders in an Emergency Medicine Department:
a 12-month retrospective study
Relatore:
Chiar.mo Prof. Stefano Pini
Candidato: Gabriele Sapia
Table of Contents 1. INTRODUCTION ... 4 1.1 BACKGROUND ... 4 1.2 CONSULTATION-LIAISON PSYCHIATRY ... 5 1.3 ANXIETY ... 7 1.4 BIPOLAR DISORDER ... 10 1.5 DEPRESSION ... 12 1.6 SUBSTANCE ABUSE ... 14
1.7 NEUROCOGNITIVE DISORDERS AND AGITATION ... 16
1.7.1 Delirium ... 17
1.7.2 Dementia ... 18
1.7.3 Psychomotor Agitation ... 18
1.8 SUICIDAL BEHAVIOUR ... 20
2. METHODS ... 21
2.1 SUBJECTS AND SETTING ... 21
2.2 EVALUATION ... 23
2.2.1 Clinical Global Impression ... 23
2.2.2 Clinical Parameters ... 24
2.4 AIM OF THE STUDY ... 27 3. RESULTS ... 28 3.1 DESCRIPTIVE ANALYSIS... 28 3.2 COMPARATIVE ANALYSIS ... 33 3.3 REGRESSION ANALYSIS ... 36 4. DISCUSSION ... 38 5. CONCLUSIONS ... 41 BIBLIOGRAPHY ... 43
1. Introduction
1.1 Background
The role of psychiatric comorbidity (PC) has been studied as a modifying and risk factor in organic pathologies, for instance the arising of depressive symptomatology in the wake of acute myocardial infarction (1) or the impact of pre-existing depressive morbidity on prognosis after acute myocardial infarction (2). On a broader scale than correlations to single organic pathologies, psychiatric comorbidity in general has been found to influence clinical course and outcome of inpatients admitted to medical wards (3). The interaction of psyche and soma is further explored through the promising lens of inflammation thanks to biological parameters e.g. C-Reactive Protein (4,5). In recent years the interaction of mental health issues with the overall health of the individual has been explored from several points of view; nonetheless epidemiological data is still mostly left for the reader to glean from publications that pursue more specific terms of inquiry (6). A clearer general picture, of paramount relevance for the improvement of healthcare and clinical practice is yet to emerge, as the United States’ recent issues with psychiatric emergencies and medical policy exemplify (7).
1.2 Consultation-Liaison Psychiatry
The modern concept of Consultation-Liaison Psychiatry (CLP) originates from studies in psychosomatic medicine between the 19th and 20th centuries (8,9)
and dates back to theories attributed to Hippocrates.
CLP is a subspecialty concerned with the care of patients with psychiatric and psychological comorbidity in a clinical setting, i.e. in general medical populations, rather than concentrating on a specific age-group or subset of disorders.
A consultation-liaison psychiatrist is tasked with (10):
• Diagnosis of psychiatric illness in medical and surgical patients. • Management of pre-existing psychiatric illness.
• Somatic presentation of psychiatric illness.
• Psychiatric and emotional complications of physical illness (e. g. oncologic patients).
“Consultation” refers to episodic referrals made for advice on diagnosis, prognosis, and management of a patient’s behavioural traits and/or therapy, up to the request to consider taking over care.
“Liaison” refers to a closer collaboration within a unit, which may involve staff support, policy development, and additional staff training as well as involvement in individual clinical cases. The balance between the liaison and consultation aspects depends on the specialty concerned (10).
1.3 Anxiety
Anxiety is defined in the DSM 5 as “The apprehensive anticipation of future danger or misfortune accompanied by a feeling of worry, distress, and/ or somatic symptoms of tension. The focus of anticipated danger may be internal or external”. It is distinguished from fear in that the latter is referred to an imminent threat (real or perceived), but both share in the role of noradrenergic activation (11,12). Anxiety disorders are differentiated from one another in the types of objects or situations that induce fear, anxiety, or avoidance behaviours.
Pathologic anxiety is distinguished from a normal emotional response by four criteria: autonomy, describing the anxiety as having to some degree “a will of its own”, automatism; intensity, which looks at the appropriateness of the intensity of response to the stimulus; duration of the feelings of distress both in acute episodes and in baseline every-day experience; and behaviour, exploring the different coping or avoiding mechanisms and their impact on functionality (13).
Anxiety and related disorders include (14): § Separation Anxiety Disorder
§ Selective Mutism § Specific Phobia
§ Social Anxiety Disorder (Social Phobia) § Panic Disorder
§ Panic Attacks in Other Disorder § Agoraphobia
§ Generalized Anxiety Disorder
§ Substance/Medication-Induced Anxiety Disorder § Anxiety Disorder Due to Another Medical Condition
Anxiety is linked to outcome of medical pathologies like heart failure (15), as mentioned above regarding depressive symptoms, and may develop in a vicious cycle of worsening organic condition accompanied by progressive elevation of anxious quota. Depression and anxiety affect the biological processes of cardiovascular function in patients with heart failure by altering neurohormonal balance via activation of the hypothalamic-pituitary-adrenal axis, autonomic dysregulation, and activation of cytokine cascades and platelets.
This shows why correct identification of anxiety in ICU patients and early involvement of a consulting psychiatrist is paramount, besides underlining the established relevance accorded in literature to the CLP department (16). Epidemiology of anxiety in acute care settings is not as well studied as the role of mood disorders, but the association with chronic medical comorbidity has been noted to be common (17).
1.4 Bipolar Disorder
Bipolar and related disorders include (14): § Bipolar I Disorder
§ Bipolar II Disorder § Cyclothymic Disorder
§ Substance/Medication-Induced Bipolar and Related Disorder § Bipolar and Related Disorder Due to Another Medical Condition
Bipolar and related disorders act as bridge between the two diagnostic classes of Schizophrenia-Psychosis and Depression in terms of symptomatology, family history, and genetics.
The main criterion for diagnosing bipolar I disorder is at least one manic episode; however, the vast majority of individuals whose symptoms meet the criteria for a fully syndromal manic episode also experience major depressive episodes during their lives.
Bipolar II disorder requires at least one episode of major depression and at least one hypomanic episode, and the diagnosis is typically accompanied by serious impairment in work and social functioning due to the length of time spent in depressive state and the instability of mood.
A large number of substances of abuse, some prescribed medications, and several medical conditions can be associated with manic-like phenomena (14). Bipolar and related disorders have been linked to higher risk of suicidality than MDD (18) and to comparable levels of disability than Depressive disorders and Schizophrenia (19). Incidence of Bipolar disorders seems to be comparable to the frequency, later described, regarding our sample (20).
1.5 Depression
Depression and related disorders include (14): § Disruptive Mood Dysregulation Disorder § Major Depressive Disorder
§ Persistent Depressive Disorder (Dysthymia) § Premenstrual Dysphoric Disorder
§ Depressive Disorder Due to Another Medical Condition
Depression is one of the most common chronic illnesses in general medical practise, second only to hypertension (13). It is estimated that 16% of the general population will experience at least one major depressive episode during their lifetime (21), which is sufficient grounds for diagnosis of Major Depressive Disorder (MDD). It is also estimated that though depression is the prime reason for psychiatric hospitalisation a large portion of MDD patients go untreated (22), in line with findings in diagnosed patients that the behavioural traits of depression often lead to poor compliance with the therapy laid out for them (23).
Depression negatively influences the outcome of other medical issues and chronic comorbidities (24,25), is associated with higher prevalence of chronic medical conditions (26) and, conversely, medical comorbidities raise the risk
of developing a depressive disorder (27). Last but not least among relevant associations is with suicidal behaviour and suicide which greatly increases the burden of the illness (28).
Depression in the acute care settings can be difficult to recognise due to the physician’s attention being called to more visible and immediate threats to survival and also because of frequent masking comorbidities and varied manifestation (29).
1.6 Substance Abuse
Substance-Related and Addictive Disorders include (14):
§ Alcohol-Related Disorders (Use, Intoxication, Withdrawal) § Caffeine-Related Disorders
§ Cannabis-Related Disorders § Hallucinogen-Related Disorders § Inhalant-Related Disorders § Opioid-Related Disorders
§ Sedative, Hypnotic and Anxiolytic-Related Disorders § Stimulant-Related Disorders
§ Tobacco-Related Disorders
§ Non-Substance-Related Disorders (Gambling)
The possible addictions are many and not all pharmacological in nature (behavioural addictions), yet all find common ground in chronic relapsing behaviour and direct recruitment of the brain’s reward pathways (30). A relevant role in the pathogenesis of addiction is played by social interaction or isolation through oxytocin (31).
In the Western nations a culture of drug or alcohol induced inebriation is common and though with much distinction in prejudice between the
substances involved, a certain amount of “youthful excess” is accepted when not expected (32). Transition from occasional recreational and social use to addiction results from genetic, developmental, and sociological vulnerabilities, combined with pharmacologically induced plasticity in brain circuitry that strengthens learned drug-associated behaviours at the expense of adaptive response to natural rewards (33). The effects of substance abuse on the brain start with access of the substance to the bloodstream, may evolve through “gateway” substances or behaviours (34) and can persist beyond detoxification(35).
Diagnostic criteria include: impaired control over modality and quantity in which the substance is consumed, up to cravings; social impairment and isolation, the change in lifestyle and shirking of social-occupational responsibilities; risky use, meaning inability to abstain from use even when it is perceived as physically or psychologically harmful; pharmacological criteria i.e. tolerance and withdrawal (14).
The nature of substance abuse disorders exposes subjects suffering from them to multiple grievous medical comorbidities (36–39) as well as nutritional deficits that impact both medical outcome and recovery from addiction (40).
1.7 Neurocognitive Disorders and Agitation
The Neurocognitive Disorders (NCD) category - "Dementia, Delirium, Amnestic and Other Cognitive Disorders" in DSM-IV (35) - encompasses the group of disorders in which the primary clinical feature is cognitive impairment, and that are acquired rather than developmental.
It includes (14):
• Delirium (Substance intoxication, Substance withdrawal, Medication-induced, due to another medical condition)
• Delirium due to multiple aetiologies (Acute, Persistent; Hyperactive, Hypoactive, Mixed level of activity)
• Major and Mild Neurocognitive Disorders (specified by aetiology: Alzheimer's disease, Frontotemporal lobar degeneration, Lewy body disease, Vascular disease, Traumatic brain injury, Substance/medication use, HIV infection, Prion disease, Parkinson's disease, Huntington's disease, Another medical condition or Multiple aetiologies; presence or absence of behavioural disturbance).
1.7.1 Delirium
Delirium is an acute and in most cases transitory (41) confusional state, a disturbance of attention or awareness with alterations of baseline cognition, accompanied by reduced orientation to environment and self, and involves memory, language and perceptual distortions; it arises acutely (hours-days) and tends to fluctuate during the course of the day, often worsening at night when external orienting stimuli decrease (42).
Delirium can occur in the context of an underlying NCD. The impaired brain function of individuals with mild and major NCD renders them more vulnerable to delirium, and a similar vulnerability is seen in 10 to 60% of the older hospitalized population and in 60 to 80% of patients in the intensive care unit who experience an episode; delirium is an important independent prognostic determinant of hospital outcomes, including duration of mechanical ventilation, nursing home placement, functional decline, long-term cognitive impairment, and death (43,44).
1.7.2 Dementia
Dementia is subsumed under the new diagnostic entity Major Neurocognitive Disorder, and it is a condition of permanent and progressive cognitive impairment, which correlates with ageing and which is estimated to rise in prevalence due to longer life expectancy and lack of curative therapeutic options for most dementing disorders (45).
The term dementia is retained in DSM-5 for continuity and may be used in settings where physicians and patients are accustomed to this term (14). Aggression, agitation and rejection of care are common behavioural symptoms that affect the quality of care for the patient and that represent a difficulty for the staff as well as a predictor of poor outcome (46,47). Behavioural symptoms add a further layer of complexity in the diagnosis and treatment of delirium superimposed on dementia (48).
1.7.3 Psychomotor Agitation
Psychomotor Agitation is a behavioural symptom defined as “excessive motor activity associated with a feeling of inner tension. The activity is usually non-productive and repetitious and consists of behaviours such as pacing, fidgeting, wringing of the hands, pulling of clothes, and inability to sit still” (14). It is a common feature of Depressive (49), Bipolar (50) and Neurocognitive
disorders (51), as well as Schizophrenia (52). Similarly to Delirium which can be an expression of lowered cognitive reserve without permanent neurocognitive damage, sporadic or “isolated“ agitation can also be found in patients who have lost consciousness due to trauma, who have been given psychoactive drugs like opioids and sedatives, or who are simply disorientated by their ailment and the unknown environment they find themselves in (53).
1.8 Suicidal Behaviour
Suicide attempt and non-lethal self-harm recognise a complex and heterogenous aetiology (54). Many studies have been conducted with the aim of better understanding and eventually preventing suicidal behaviour (55–57), but maybe because of the diversified and growing fronts on which the battle is fought – genetics, family history, sociology, psychiatric and medical anamnesis - no definitive approach has emerged to address the issue.
Progress has been made in better identifying the factors that delineate the population at risk: psychiatric (28,58) and medical comorbidity (13,59) are at the forefront.
Suicidality and suicidal ideation (60) are often a target symptom of psychopharmacologic therapy (61) in patients with diagnosed psychiatric disorders (62). Discontinuation of therapy is associated with suicide completion (54): a thorough management of suicidal behaviour includes making sure patients and their families understands the importance of follow-up, since PC patients are at risk of low compliance.
Suicidal behaviour can manifest all through life, but there are peaks in incidence around adolescence (57), in later life (59), following psychologically taxing life events (28,55,63,64) and a higher risk was recorded in subjects with early-life adversity (65).
2. Methods
2.1 Subjects and Setting
This retrospective cohort study was conducted as a collaborative effort between the Liaison Psychiatry Unit and the Acute Care wards at the Hospital of Pisa (AOUP), where the implementation of hospital-wide computerized information sharing systems made it possible for us to construct a comprehensive database. 160 subjects were enrolled, all of whom were admitted to the Emergency Medicine Department, comprised by the distinct entities of the University teaching ward (Medicina d’Urgenza Universitaria, MUU) and the Hospital ward (Medicina d’Urgenza Ospedaliera, MUO), in a one-year time-frame between September 2017 and August 2018.
12,50% 17,50% 3,13% 14,38% 11,88% 11,88% 15% 13,75% 16,25% 10,00% 2,50% 10,00% 12,50% 8,75% 30,00% 10,00% 8,75% 25,00% 3,7… 18,75% 11,25% 15,00% 17,50% 5,00% 10,00% 15,00% 20,00% 25,00% 30,00% 35,00%
DIAGNOSIS AT TIME OF
HOSPITALISATION
80 subjects were enrolled in the study group on the basis of a formal request from the inpatient ward to the Liaison Psychiatry Unit for a consultation.
The study group subjects are 39 males (48,8%), 41 females (51,2%), ages between 18 and 94 (mean 67,5), admitted with primary medical diagnoses classified as: Cardiovascular, Gastrointestinal, Pulmonary, Neurological, Traumatic, Psychiatric or Other.
Upon request of the attending physician they were evaluated by a Liaison Psychiatrist who assigned psychiatric diagnoses (when not already known from anamnesis) classified as: NCD, Depressive, Substance-related, Bipolar, Anxiety, Suicidality, and Other.
80 subjects were enrolled in the control group from the same wards, matching them by age and sex to the study subjects, excluding patients who had received psychiatric care during their stay.
In-hospital mortality during our time-frame of interest in the sample population was comparable with ward-wide mortality (respectively 4,4% and 5,1%).
2.2 Evaluation
2.2.1 Clinical Global Impression
All patients were evaluated using the Clinical Global Impression Scale (CGI, 47), an instrument which takes under consideration the clinician’s experience of patients with a same diagnosis, and thus partly subjective in nature much like the commonly used Wells Score in Pulmonary Embolism (67).
Though modified since its original design to fit specific illnesses and reflect the changing reality of psychiatric consensus (68–70), the CGI is composed of three main items:
• Item 1: Severity Scale (CGI-S) • Item 2: Improvement Scale (CGI-I) • Item 3: Efficacy Index
For the purposes of our study we made use of items 1 and 2, both 7-point scales ranging respectively from 1= “not ill” to 7= “among the most extremely ill”, and 1= “very much improved” to 7= “very much worse”.
acute psychiatric episodes in acutely medically ill patients) and between the two groups (ample diversity of main cause for hospitalisation and comorbidities), requiring in our judgement a larger sample to adequately interpret.
Patients were assigned their scores on the basis of the clinical experience of the attending physician and psychiatrist, corroborated by narrative data compiled by the staff throughout the hospitalisation period. The scales were used both on study and control subjects, accounting for mental as well as medical severity and improvement despite the main scope of the CGI being mental health, so as to render the two groups uniformly evaluated and comparable.
2.2.2 Clinical Parameters
Variables we took under consideration are: sex and age, matching them in the non-PC group to those recorded for the PC group; medical diagnosis reason for admission and psychiatric diagnosis; presence/absence of agitation, delirium and cognitive impairment; psychopharmacological therapy, opioid and corticosteroids use in the study patients; previous psychiatric anamnesis; length of stay (LoS); C-Reactive Protein as organic marker.
2.3 Statistical Analysis
Statistical analysis was performed using SPSS software (71). Frequency analysis was computed to describe and characterize each group as well as the whole sample population. Significance level was set to p = .05.
The groups were then confronted against each other by frequency of each item of the database; we compared gaussian variables such as LoS between groups or Los by presence/absence of cognitive impairment with Student’s T Test for independent samples, which tests the hypothesis that the two groups of variables are independent but identically distributed; ordinal and non-gaussian variables like CRP were studied with Mann-Whitney U Test for non-parametric variables, which does not require the assumption of normal distribution and can be used to determine whether two independent samples were selected from populations with the same distribution (mean rank reported between parentheses); categorical variables such as expected versus observed frequencies of agitation, delirium and medical diagnoses between groups were studied with Pearson’s Chi-Squared Test.
population) to retro-engineer a prediction model that would apply to our group distribution between PC and non-PC patients, which in turn is indicative of which variables characterised our sample and how by calculating the contribution of individual predictors. Lastly, we performed a multiple linear regression with analysis of variance to explore contribution to the determination of LoS.
2.4 Aim of the Study
The twofold aim of this study is to provide epidemiological data regarding the frequency of psychiatric pathology in the acute care setting, and to investigate the interaction of organic pathology and mental health issues in terms of resources (LoS) and clinical outcome in comparison with patients who did not have mental health issues before their discharge.
3. Results
3.1 Descriptive Analysis
Out of 160 subjects 48,8% were male and 51,2% female, ages between 18 and 94 (mean 67,5 ± 21,1).
The Length of Stay was between 1 and 56 days (mean 8,9 ± 7,7).
C-Reactive Protein was between 0,00 mg/dl and 33,77 mg/dl (mean 3,45 ± 5,51).
Primary medical diagnoses in the study group were: Cardiovascular 16,25%, Gastrointestinal 10%, Pulmonary 10%, Neurological 12,5%, Traumatic 8,75%, Psychiatric 30% or Other 12,5%.
Figure 2: Distribution of Primary Diagnosis in Study Patients.
Cardiovascular 16% Gastrointestinal 10% Neurologic 12% Pulmonary 10% Traumatic 9% Psychiatric 30% Other 13%
Primary medical diagnoses in the control group were: Cardiovascular 8,8%, Gastrointestinal 25%, Pulmonary 18,8%, Neurological 11,3%, Traumatic 15%, Psychiatric 0%, and Other 21,3% (e.g. Acute Kidney Injury, Anaemia, General Functional Decline).
Figure 3: Distribution of Primary Diagnosis in Control Patients.
Cardiovascular 9% Gastroinestinal 25% Neoplasm 4% Pulmonary 19% Neurological 11% Traumatic 15% Psychiatric 0% Other 17%
The whole-sample CGI-S score assigned at time of admission was distributed as follows:
Table 1 Whole-sample distribution of clinical severity
Score Description Percentage
1 Not ill 0% 2 Borderline 5% 3 Mildly ill 15% 4 Moderately ill 35% 5 Markedly ill 30% 6 Severely ill 11,3%
7 Among the most extremely ill 3,8%
The whole-sample CGI-I score at time of discharge from the hospital was distributed as follows:
Table 2 Whole-sample distribution of clinical improvement
Score Description Percentage
1 Very much improved 20,6%
2 Much improved 33,1%
3 Minimally improved 30%
4 No change 6,9%
5 Minimally worse 3,8%
6 Much worse 1,3%
At least one episode of Psychomotor Agitation was recorded in 22,5% of subjects in total: 5% of control subjects and 40% of study subjects.
Delirium was experienced by 19,4% of subjects in total: 5% of control subjects and 33,8% of study subjects.
Mild cognitive impairment was present in 3,8% of subjects, moderate cognitive impairment in 12,5% and severe cognitive impairment in 11,3%.
Psychiatric diagnoses in the study group were: NCD 21,25%, Depressive 17,5%, Substance-related 12,5%, Bipolar 5%, Anxiety 8,75%, Suicidality 18,75%, and Other 11,25% (e.g. isolated agitation).
Anxiety 9% Bipolar 5% Depressive 19% Suicidality 20% Other 12%
Psychopharmacological therapy in the study group was not undertaken in 3,75% of subjects; therapy with a single psychoactive medication was undertaken in 30%, two psychoactive medications in 31,25%, three in 16,25%, four in 7,5%, five in 6,25%, six in 3,75% and seven psychoactive drugs in 1,25% of patients.
16,3% of the study group population were prescribed Corticosteroid therapy, and 16,3% received Opioid medication.
3.2 Comparative Analysis
The comparison of Length of Stay between the two groups was found to be statistically significant using Student’s T Test (p = .001), and the result was confirmed conducting an independent samples Mann-Whitney’s U Test (mean rank 90,89 in the study group, 70,11 in the control group; Z = 2,8; p < .005). This shows that patients with any psychiatric diagnosis (PC-group) had a significantly longer hospitalisation than did patients with no psychiatric diagnosis (control group). LoS in depressed patients confronted with both the rest of the study subjects and the whole sample did not show significant differences; exploring the effect of psychiatric diagnosis on LoS with a Variance Homogeneity Test revealed that no single psychiatric diagnosis had relevance with the exception of patients admitted for suicidal behaviour who tended to have a shorter stay (mean 12,6 ± 9,8 days in non-suicidal patients, 3,9 ± 2,2 in suicidal patients; t = 6,5; p < .005).
Psychomotor agitation and delirium were significantly more frequent in the study group (Chi-Squared Test: P < 0.05). Cognitive impairment was statistically different in the two groups as seen with Mann-Whitney’s U Test (p
LoS was found to be significantly longer in patients who had episodes of psychomotor agitation (t = -3,27; p = .002), delirium (t = -2,64; p = .009) and who suffered from cognitive impairment (t = -2,85; p = .006).
Table 3 Impact of psychiatric comorbidity on hospital stay in Emergency Medicine Units
Psychiatric Disorder
Variables* All sample Yes (n = 80) No (n = 80)
Sociodemographic Age, years 67,5 ± 21,1 67,5 ± 21,1 67,5 ± 21,1 Male, n (%) 48,8% 48,8% 48,8% Female, n (%) 51,2% 51,2% 51,2% Medical Medical comorbidity 85 % 70 % 100 %
Length of Stay, days, mean 8,9 ± 7,7 10,95 ± 9,5 6,9 ± 4,5
In-hospital Death, n (%) 4,375 % 5 % 3,75 %
Reason for hospitalization, n (%)
Cardiovascular 12,5 % 16,25 % 8,75 % Gastrointestinal 17,5 % 10 % 25 % Neoplasms 3,125 % 2,5 % 3,75 % Pulmonary 14,375 % 10 % 18,75 % Neurological 11,875 % 12,5 % 11,25 % Trauma 11,875 % 8,75 % 15 % Psychiatric 15 % 30 % 0 % Other 13,75 % 10 % 17,5 %
The difference of Primary diagnosis distribution was statistically significant between the two groups (Chi-Squared Test: P < 0.05).
The CGI scores were confronted between groups with Mann-Whitney’s U Test for independent samples. While clinical improvement expressed on the CGI-I scale did not relevantly differ between groups, clinical severity of illness in the form of CGI-S was significantly higher in the control group (mean rank 91,84) than in the study group (mean rank 69,16; Z = -3,2; p = .001).
CRP studied with Mann-Whitney’s U Test was significantly higher in psychiatric patients (mean rank 88,33) than in the medical counterparts (mean rank 72,67; Z= 2,17; p < 0.05). Furthermore, higher values were found when cross-referencing for presence of agitation (p < .001), delirium (p = .005) and cognitive impairment (p < .001).
3.3 Regression Analysis
To better understand the characterisation of study group patients, with psychiatric diagnosis, a group prediction model was drafted via logistic regression with a Hosmer-Lemeshow test (Cox-Snell’s R-Squared = .535; Negelkerke’s R-Squared = .714) using as significant variables CGI-S, LoS, CRP, agitation, delirium and cognitive impairment.
Table 4 Variables in Logistic Regression Equation
B (S.E.) O.R. P CGI-S - 1,45 (0,31) 0.235 < .001 LoS 0,17 (0,05) 1,183 = .002 CRP 0,09 (0,06) 1,092 = 1.65 Agitation 2,69 (0,77) 14,772 < .001 Delirium 1,94 (0,85) 6,980 = .023 Cognitive Impairment 0,67 (0,3) 1,954 = .025 Constant 2,75 (1,04) 15,641 = .008
B: Regression Coefficient; S.E.: Standard Error; O.R.: Odds Ratio
The model correctly predicts which subjects belong to which group in 88,1% of cases with 90% accuracy for control group subjects and 86,3% for study subjects.
of psychiatric diagnosis, 18% more per day; CRP does not adequately contribute to the prediction. Delirium and agitation correlate with probable psychiatric diagnosis, increasing its likelihood respectively by a seven- and fourteen-fold factor.
In order to more thoroughly investigate the factors influencing LoS we ran a multiple linear regression with ANOVA, using group, CGI-S, cognitive impairment, agitation and delirium as independent variables.
Table 5 Variables in Multiple Linear Regression Equation.
B (S.E.) t P Agitation 4,79 (2,65) 2,947 = .004 Delirium -0.88 (1,62) -0,504 = .615 Cognitive impairment 3,24 (1,76) 2,226 = .027 CGI-S 0,14 (1,45) 0,257 = .798 Group 1,97 (0,55) 1,428 = .155 Constant 5,51 (2,65) 2,080 = .039
4. Discussion
Our analysis of LoS distribution between the groups confirmed that PC correlates with longer hospital stay. The independent contributions of cognitive impairment, agitation and delirium, and the general correlation with presence of any psychiatric diagnosis would seem to indicate a more tumultuous clinical course in the study subjects than would be expected relative to their comparative severity. Perhaps this was because of lessened ability to comply with therapy (e.g. withdrawing IV lines) and difficulties expressing one’s needs and correctly assessing and adapting to a new environment, all common features of mental illness.
The role of cognitive impairment, delirium and agitation is corroborated In literature (72–74)
In our sample depression was not found to have any role in determining LoS, and literature seems to be divided on this issue with many findings in favour (75,76) and many opposed (77,78).
Suicidal behaviour was found to correlate with shorter LoS. This was probably due to the fact that most of the suicidal patients in our study group were younger people without chronic comorbidities, who attempted suicide by
overdosing oral prescription medication, so they mostly received support therapy and were discharged when the critical window was over.
Medical diagnosis was significantly differentiated as expected given the 30% of admissions due to psychiatric causes in the study group versus 0% in the control group, but while useful in the characterisation of psychiatrically comorbid patients, it was not relevant in defining LoS or outcome.
Analysis of therapy was conducted to study possible interactions between psychoactive drugs and drugs known to have Central Nervous System adverse reactions. No pattern of interaction was found.
The similar distribution of CGI-I scores despite varying degrees of sickness and the distinct nature of the two groups of patients seems to confirm that they were both well managed.
Increasing clinical severity was found to directly correlate with absence of psychiatric diagnosis as expected in a medical ward that manages patients in need of acute care, particularly considering that the quota of patients
CRP was significantly higher in the PC-group and in patients who presented delirium, agitation or cognitive impairment, conforming our data to literature consensus describing the role of inflammation and anti-inflammatory drugs (off-label Liraglutide for instance) (79) in mental illness. Perhaps CRP’s notorious aspecificity can account for the lack of predicting value it was found to have as pertains to presence or absence of PC and to LoS.
5. Conclusions
This retrospective study began on the basis of the hypothesis that patients with PC are distinct from other medical inpatients. Our two groups were selected with criteria intended to minimise discrimination of medical characteristics among subjects, with the exception of presence/absence of PC, so that the data collected would be as significant as possible in defining the influence of mental health issues on clinical course and outcome.
The relevance of this study is limited by the size of its sample and the implicit championing bias of PC patients going unrecognised, for example because of heightened relevance of other comorbidities.
The fact that longer hospitalisation and lesser medical severity characterised the PC-group seems to validate of the design of our study: PC would then act as an adjunct factor to medical severity, though not through simple summation but rather via complex and yet to be explored interactions.
The presence of mental health-related issues in a medically ill patient would make them comparable in predicted need for hospitalisation to more severely ill but mentally healthy patients.
The absent distinction between CGI-I distribution between groups indicates that in-hospital approach to PC patients is correct, so follow-up and
prevention should be analysed and improved next.
Recognition of medical patients with PCs and early management could help prevent negative prognostic events such as delirium from manifesting, particularly in cognitively impaired patients who are known to be at greater risk, and ultimately take the medical community one step further in giving a relevant part of the population a better quality of care and outcome, while saving on National Health Service funds.
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