Dr. Maldonado is Medical Director of Psychosomatic Medicine and Chief of Psychiatric Emergency Services and Transplant Psychiatry at Stanford University Medical Center. He is board certified in Adult Psychiatry, Psychosomatic Medicine, Forensic Psychiatry, Addiction Medicine, and Forensic Medicine. He is Chair of the Stanford School of Medicine – Faculty Senate and President of the American Delirium Society.
His research lab developed the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) a tool created to assess the psychosocial candidacy of organ transplant and ventricular assisted devices (VADs) candidates. In addition, his research has led the field of Psychosomatic Medicine with the development of tools for the prediction and assessment of various neuropsychiatric disorders; including the development of a new tool for the timely and accurate diagnosis of delirium: the Stanford Proxy Test of Delirium (S-PTD); the Stanford Algorithm for Predicting Delirium (SAPD), a tool to help predict patients at risk for developing delirium; and the Prediction of Alcohol Withdrawal Severity Scale (PAWSS). He has developed management protocols and algorithms for the prevention and treatment of delirium; as well as novel pharmacological techniques (benzodiazepine-sparing protocol) for the prophylaxis and treatment of complicated alcohol withdrawal syndromes.
Dr Maldonado has been the recipient of multiple awards and recognitions, including: the 2004 – Dlin/Fischer Award for significant achievement in clinical research from the Academy of Psychosomatic Medicine for work on reduction of post-operative and critical care delirium; the 2009 – Dorfman Award for Best Original Research from the Academy of Psychosomatic Medicine for development of the Stanford Integrate Psychosocial Assessment for Transplantation (SIPAT); the 2014 – Dlin/Fischer Award for significant achievement in clinical research from the Academy of Psychosomatic Medicine for the development of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS); the 2014 – Herbert Spiegel Award for Hypnosis Research from the Department of Psychiatry at Columbia University & New York State Psychiatric Institute; the 2016 – Sawlow Memorial Award on Neuroscience from the Oregon Health & Science University for his work on the pathophysiology and management of delirium; the 2017 – Franz-Köhler-Inflammation-Award from the German Society of Anesthesiology and Intensive Care Medicine (DGAI) for extraordinary achievements in research on inflammation and its relationship to the pathophysiology of delirium; and the 2018 – Eleanor and Thomas P. Hackett Memorial Award by the Academy of Consultation-Liaison Psychiatry, the Academy’s highest honor, for distinctive achievements in CLP training, research, clinical practice, and leadership.
- Psychosomatic Medicine
- Forensic Psychiatry
Chair, Ethics Committee, Society for Clinical and Experimental Hypnosis (1995 - 1997)
Medical Director, Psychosomatic Medicine Service, Stanford Hospital and Clinic (1995 - Present)
Admissions Panel, Stanford University Medical School (1998 - 2008)
Co-Chair, Ethics Committee, Stanford University Medical Center (2001 - 2009)
Committee on Xenotransplantation, The Secretary of Health & Human Services (2004 - 2008)
National Panel on Transplantation, National Institute of Health (2004 - 2008)
Senator-at-Large, Stanford School of Medicine (2009 - 2013)
Fellowship Director, Psychosomatic Medicine Program, Stanford School of Medicine (2010 - Present)
Departmental Senator, Psychiatry, Stanford School of Medicine (2011 - 2019)
Member, Board of Directors, American Delirium Society (2012 - Present)
Chief, Psychiatry Emergency Service, Stanford Hospital & Clinics (2015 - Present)
Chair, Stanford School of Medicine Faculty Senate, Stanford School of Medicine (2016 - 2018)
President, American Delirium Society (2017 - 2018)
Honors & Awards
Charles Shagass, MD Award, for meritorious scholarly work during residency, Temple University School of Medicine (1992)
Fellow, American College of Forensic Psychiatry (1996)
Fellow, Academy of Psychosomatic Medicine (1996)
2001-Teacher of the Year Award, Psychiatric Times (2001)
Best Paper on the Application of Hypnosis, American Psychological Association (2002)
2003 Kaiser Awards for Clinical Teaching, Stanford University School of Medicine (2003)
Best Researcher/Author Presentation, 17th World Congress on Psychosomatic Medicine (2003)
DLIN/Fischer Award, for significant achievement in clinical research, Academy of Psychosomatic Medicine (2004)
Teacher of the Year Award, Department of Psychiatry & Behavioral Sciences, Stanford University (2004)
Dorfman Award, for Best Case Report, Academy of Psychosomatic Medicine (2006)
Dorfman Award for Best Original Research, Academy of Psychosomatic Medicine (2009)
Teacher of the Year Award, Department of Psychiatry & Behavioral Sciences, Stanford University (2009)
Research Poster of the Year Award, Academy of Psychosomatic Medicine (2012)
Research Poster of the Year Award, Society for Academic Emergency Medicine (2013)
Dlin/Fischer Award for significant achievement in Clinical Research, Academy of Psychosomatic Medicine (2014)
Herbert Spiegel Award for Hypnosis Research, Department of Psychiatry at Columbia University & New York State Psychiatric Institute (2014)
Research Poster of the Year Award, Academy of Psychosomatic Medicine (2014)
Visiting Professorship Award, Academy of Psychosomatic Medicine (2014)
Sawlow Memorial Award on Neuroscience, Oregon Health & Science University and the Portland International Neuroscience Symposium (2016)
Franz-Köhler-Inflammation-Award, German Society of Anaesthesiology and Intensive Care Medicine (2017)
2018 – Eleanor and Thomas P. Hackett Memorial Award, Academy of Consultation-Liaison Psychiatry (2018)
Boards, Advisory Committees, Professional Organizations
Member, National Panel on Transplantation, National Institute of Health (2004 - 2008)
Member, Secretary of Health & Human Services Committee on Xenotransplantation, Department of Health & Human Services (2004 - 2008)
President, Board of Directors, American Delirium Society (2017 - 2018)
Member, Governance Committee, Academy of Consultation-Liaison Psychiatry (2010 - 2019)
Member Scientific Advisory Board, Network for Investigation of Delirium in the United States (NIDUS) (2016 - 2018)
Member, Scientific Advisory Board (SAB), Network for Investigation of Delirium across the U.S. (NIDUS) (2017 - 2018)
Chair, Faculty Senate, Stanford School of Medicine (2016 - 2018)
Member, Panel: assigned to develop a new draft of the National Patient Safety Goal (NPSG) requirements on patients at risk for suicide, Joint Commission Standards Review Panel (2018 - Present)
Member Working Group on the Development of the ATS Research Statement on Severe Alcohol Withdrawal Syndrome (SAWS), American Thoracic Society (ATS) (2019 - Present)
Member of Board of Directors, American Delirium Society (2012 - Present)
Residency: Temple University Hospital Psychiatry Residency (1992) PA
Internship: Temple University Hospital Psychiatry Residency (1989) PA
Board Certification: American Board of Addiction Medicine, Addiction Psychiatry (2012)
Board Certification: American Board of Psychiatry and Neurology, Psychosomatic Medicine (2005)
Board Certification: American Board of Psychiatry and Neurology, Psychiatry (1993)
Fellowship: New England Medical Center (1993) MA
Medical Education: Ponce School Of Medicine (1988) PR
Diplomate, ABPN, Forensic Psychiatry (2005)
Diplomate, ABPN, Psychosomatic Medicine (2005)
Diplomate, American Board Forensic Examiner, Forensic Medicine (1996)
Diplomate, American Board Forensic Medicine, Forensic Medicine (1996)
Diplomate, ABPN, General Psychiatry (1993)
Fellowship, New England Medical Center, Psychosomatic Medicine (1993)
Resident, Temple University Hospital, Residency in Psychiatry (1992)
MD, Ponce School of Medicine, Medicine (1988)
Current Research and Scholarly Interests
His research interests include: delirium, alcohol withdrawal in the medically-ill, solid organ transplantation, and the medical use of hypnosis. For the last 24 years he has been studying the psychosocial aspects of solid organ and composite tissue transplantation; which has led to the development of the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) to assess the psychosocial candidacy of organ transplant and ventricular assisted devices (VADs). Over the last 20 years he has studied the diagnosis, neurobiology, prevention and management of delirium; developing prevention and treatment protocols, and writing numerous manuscripts and chapters in the topic. More recently, his research team has developed a new tool for the timely and accurate diagnosis of delirium: the Stanford Proxy Test of Delirium (S-PTD) and a tool to help predict those patients at risk for developing delirium, the Stanford Algorithm for Predicting delirium (SAPD). Over the last 6 years, Dr Maldonado has led his research team in studying the neuropathophysiology of alcohol withdrawal syndrome and its relationship to delirium tremens. This eventually led to the development of a new tool for the prediction of patients at risk of severe AWS: the Prediction of Alcohol Withdrawal Severity Scale (PAWSS); and novel pharmacological techniques for the prophylaxis and treatment of complicated alcohol withdrawal syndromes.
A Comparison of Lorazepam and Diazepam in the Treatment of Alcohol Withdrawal
The purpose of this study is to compare the efficacy of two commonly used medications in the treatment of alcohol withdrawal, diazepam and lorazepam.
Stanford is currently not accepting patients for this trial.
A Pilot Study of "Stanford Proxy Test for Delirium" (S-PTD)
Although there are several tools available for the screening of delirium among the medically ill, they all have some limitations. First, none of the available tools have been validated against newly developed and published DSM-5 (Diagnostic and Statistical Manual) or ICD-10 (International Statistical Classification of Diseases and Related Health Problems) criteria. Additionally, all the screening/diagnostic tools presently available have the same limitation, they all require significant patient involvement and participation (e.g., questions and activities) in order to complete the assessment. By definition, delirium is a neuropsychiatric disorder characterized by disturbance in attention and awareness, and additional disturbance in cognition (e.g., memory deficit, disorientation), language, visuospatial ability, or perception. The intrinsic characteristics of delirium seem to interfere with the patient's ability to participate and complete many of the tasks associated with delirium evaluation itself. Finally, most available tools seem to narrowly focus on some neurocognitive areas of delirium, but not being comprehensive enough. In contrast, the S-PTD is designed so it can be completed by the nursing staff caring for the patients, the medical personnel most intimately involved with the care and aware of the behaviors exhibited by the patient during the course of their hospital stay. The idea is that nurses will complete the screening tool (hence the term "by proxy"), based on the behaviors and interactions observed during the course of a conventional "nursing shift", to determine whether the patient meets current neuropsychiatric criteria for the diagnosis of delirium.
Stanford is currently not accepting patients for this trial.
Is Dexmedetomidine Associated With a Lower Incidence of Postoperative Delirium When Compared to Propofol or Midazolam in Cardiac Surgery Patients
The purpose of this study is to determine whether the use of dexmedetomidine, a selective α2-adrenergic receptor agonist with sedative, analgesic, and antinociceptive properties, would be associated with a lower incidence of delirium when compared to propofol and midazolam. We hypothesize that sedation with dexmedetomidine following cardiac surgery with CPB will be associated with a lower incidence of postoperative delirium.
Stanford is currently not accepting patients for this trial.
The "Prediction of Alcohol Withdrawal Severity Scale" (PAWSS)
Although there are several tools that can be used to evaluate the severity of ongoing alcohol withdrawal syndrome (AWS), there is no available tool that can predict which patients are at risk for developing AWS at the time admission, before the patient has developed AWS. Unfortunately, there are severe symptoms of alcohol withdrawal (e.g., seizures) which may develop early in the hospitalization, and before the development of other systemic symptoms which may warn medical personnel of the possibility of impeding alcohol withdrawal (e.g., autonomic instability, delirium). The goal of this study is to evaluate the psychometric properties (e.g., predictive validity) of a new tool, the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), on identifying which patients are at risk for developing complicated AWS (i.e., seizures, hallucinosis, delirium tremens) among hospitalized, medically ill patients.
Stanford is currently not accepting patients for this trial.
Valproic Acid for Treatment of Hyperactive or Mixed Delirium in ICU
Delirium is the most often encountered psychiatric diagnosis in the general hospital, with incidence up to 85% in the intensive care unit (ICU) setting and with significant consequences on patients' morbidity and mortality. Currently, although not FDA approved, antipsychotics are often considered the first-line pharmacological treatment. However, there can be limitations to their use, including side effects or lack of efficacy. Valproic acid (VPA) is one of the alternatives at times used in such patients which from limited case series data appears to be helpful and tolerated. VPA can provide relief from agitation that poses a threat to the safety and recovery of the patient. Moreover, mechanistically it addresses the neurochemical and cellular abnormalities inherent in delirium (it has NMDA-antagonist, anti-dopaminergic, GABAergic,anti-inflammatory, anti-apoptotic, and histone deacetylase inhibitor properties, among others). The purpose of this study is to evaluate the efficacy and tolerability of the VPA in the first known to us randomized controlled trial.
Stanford is currently not accepting patients for this trial. For more information, please contact Shengchun Wang, Ph.D, 518-334-2513.
Graduate and Fellowship Programs
When the Patient Says No to Transplant: A Life Well Lived and Well Ended
2020; 61 (4): 379–84
View details for Web of Science ID 000549388900009
- The Stanford ALD-exception protocol: Assessment & outcomes of Liver transplant recipients with alcohol-related liver disease and limited sobriety using an adaptation of the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) PERGAMON-ELSEVIER SCIENCE LTD. 2020
- The assessment of living donor transplant candidates: The development of the SIPAT-D PERGAMON-ELSEVIER SCIENCE LTD. 2020
- Use of Guanfacine as an alternative to Dexmedetomidine for sedation and agitation management in the Intensive Care Unit PERGAMON-ELSEVIER SCIENCE LTD. 2020
- COVID-19-Associated Hyperactive Intensive Care Unit Delirium With Proposed Pathophysiology and Treatment: A Case Report. Psychosomatics 2020
A Study of the Psychometric Properties of the "Stanford Proxy Test for Delirium" (S-PTD): A New Screening Tool for the Detection of Delirium
2020; 61 (2): 116–26
View details for Web of Science ID 000519299000002
The Psychosocial Assessment of Transplant Candidates: Inter-Rater Reliability and Predictive Value of the Italian Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT)
2020; 61 (2): 127–34
View details for Web of Science ID 000519299000003
Genetic disease and intellectual disability as contraindications to transplant listing in the United States: A survey of heart, kidney, liver, and lung transplant programs.
Discrimination based on disability is prohibited in organ transplantation, yet studies suggest it continues in listing practices for intellectual disability and genetic diseases. It is not known if this differs between adult and pediatric programs, or by organ type. We performed an online, forced-choice survey of psychosocial listing criteria for adult and pediatric heart, kidney, liver, and lung transplant programs in the United States. Of 650 programs contacted, 343 (52.8%) submitted complete. A minority of programs had formal listing guidelines for any condition considered (Down Syndrome, Duchenne Muscular Dystrophy, Becker Muscular Dystrophy, DiGeorge Syndrome, and Wolf Hirschhorn Syndrome; and mild [IQ < 70] and severe [IQ < 35] intellectual disability), although a majority had encountered most. Pediatric programs were significantly (P < .02) more lenient in the level of contraindication to listing for all genetic conditions considered except Duchenne Muscular Dystrophy, and for mild and severe intellectual disability. Level of contraindication differed significantly by organ type (heart, lung, liver, and kidney) for Duchenne Muscular dystrophy (P = <.001), Becker Muscular Dystrophy (P < .001), DiGeorge Syndrome (P < .001), Wolf-Hirschhorn syndrome (P = .0012), and severe intellectual disability (P < .001). There is significant variation among transplant programs in availability of guidelines for as well as listing practices regarding genetic diseases and intellectual disability, differing by both adult vs pediatric program, and organ type. Programs with absolute contraindications to listing for specific genetic diseases or intellectual disability should reframe their approach, ensuring individualized assessments and avoiding elimination of patients based on membership in a particular group.
View details for DOI 10.1111/petr.13837
View details for PubMedID 32997378
The Psychosocial Assessment of Transplant Candidates: Inter-Rater Reliability and PredictiveValue of the Italian Stanford Integrated Psychosocial Assessment forTransplantation.
BACKGROUND: The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) is a comprehensive instrument developed to accurately assess the main pretransplant psychosocial risk factors that may impact transplant outcomes.OBJECTIVE: As neither established assessment procedures nor standardized tools designed to perform pretransplant psychosocial evaluation are currently available in Italy, the present study was designed to develop and preliminarily validate the Italian version of the SIPAT.METHODS: First, our team developed the Italian version of the SIPAT, following standard forward-back translation procedures. Then, the Italian version of the SIPAT was retrospectively and blindly applied to 118 randomly selected transplant cases (40 heart, 40 lung, and 38 liver) by 2 independent examiners. Information about the patients' final transplant listing recommendation (i.e., listing vs. deferral) was independently collected from the respective transplant teams.RESULTS: The inter-rater reliability of the Italian version of the SIPAT scores was substantial (Cohen's kappa=0.77; P<0.001). Moreover, the predictive value of the SIPAT ratings on the final transplant listing recommendation (i.e., listing vs. deferral) for each examiner was significant (both P<0.05).CONCLUSION: Current findings suggest that SIPAT is a promising and reliable instrument in its Italian version. Given these excellent psychometric characteristics, the use of the SIPAT as part of the pretransplant psychosocial evaluation in Italian medical settings is highly encouraged.
View details for DOI 10.1016/j.psym.2019.11.008
View details for PubMedID 31928784
A Study of the Psychometric Properties of the "Stanford Proxy Test for Delirium" (S-PTD): ANew Screening Tool for the DetectionofDelirium.
BACKGROUND: Delirium is a prevalent neuropsychiatric disorder associated with increased morbidity and mortality. Half the cases remain misdiagnosed.OBJECTIVE: Assess the effectiveness of the Stanford Proxy Test for Delirium (S-PTD) in detecting delirium in an inpatient setting.METHODS: This is a comparison study. Daily assessment with S-PTD, by the patient's nurse, and a neuropsychiatric assessment by a psychiatrist. Assessments were blinded. Inclusion criteria included 18 years or older. Exclusion criteria included patient's or surrogate's unwillingness to participate, inability to consent if a surrogate was not available, and inability to communicate in English or Spanish. A total of 309 patients were approached: 27 declined participation, 4 were excluded, and 278 subjects were followed up throughout their hospital stay. In the end, 78 were excluded for lack of neuropsychiatric assessment, S-PTD, or both. One was excluded for lack of demographic data. The sensitivity and specificity of the S-PTD in detecting delirium when compared with a neuropsychiatric assessment.RESULTS: Participants were on average 60.8 years old and 54.3% were male. Patients who developed delirium were, on average, older (15.12 y, confidence interval: 8.94-21.32). A total of 199 patients were analyzed; 43 patients (21.6%) met criteria for delirium. S-PTD detected 67 days with delirium (16.5%) of 405 hospital days, while neuropsychiatric evaluation identified 83 (20.5%). S-PTD had a sensitivity of 80.72% and a specificity of 90.37%.CONCLUSION: S-PTD is an effective, comprehensive, and simple screening tool for delirium, which is robust despite fluctuating symptoms and lack of cooperation. The use of S-PTD may enhance early diagnosis of delirium.
View details for DOI 10.1016/j.psym.2019.11.009
View details for PubMedID 31926650
- When the Patient Says No to Transplant: A Life Well Lived and Well Ended. Psychosomatics 2019
Translation, adaptation, and reliability of the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) in the Spanish population.
BACKGROUND: Psychosocial risk factors influence the course of transplantation. Psychosocial evaluation is an important part of pre-transplantation evaluation processes, yet there are no standardised instruments in Spanish.OBJECTIVE: To translate, adapt, and test the reliability of the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) in organ and cell transplantation patients in the Spanish context.METHOD: A Spanish version was developed and adapted using WHO's guidelines. The first 30 candidates' SIPAT interviews were recorded and scored by four independent examiners to test the inter-rater reliability. The internal consistency of the SIPAT items was calculated with a sample of 150 heart, liver, and allogeneic haematopoietic stem cell transplant candidates. Evaluations were conducted by SIPAT-trained and transplantation-experienced clinical psychologists and psychiatrists.RESULTS: SIPAT achieved excellent intraclass correlation reliability coefficients between investigators (ICC = 0.93 for the general score and from 0.77-0.94 for domain scores). Good internal consistency was found with a Cronbach's alpha of 0.84 (from 0.69-0.71 for domains).DISCUSSION: This study presents the translated and adapted version of SIPAT. It has been found to have strong inter-rater reliability and good internal consistency. Further research is needed to confirm reliability (e.g.: test-retest) and establish its validity (e.g.: concurrent, predictive). This article is protected by copyright. All rights reserved.
View details for DOI 10.1111/ctr.13688
View details for PubMedID 31392778
Medical Contraindications to Transplant Listing in the USA: A Survey of Adult and Pediatric Heart, Kidney, Liver, and Lung Programs.
World journal of surgery
INTRODUCTION: Listing practices for solid organ transplantation are variable across programs in the USA. To better characterize this variability, we performed a survey of psychosocial listing criteria for pediatric and adult heart, lung, liver, and kidney programs in the USA. In this manuscript, we report our results regarding listing practices with respect to obesity, advanced age, and HIV seropositivity.METHODS: We performed an online, forced-choice survey of adult and pediatric heart, kidney, liver, and lung transplant programs in the USA.RESULTS: Of 650 programs contacted, 343 submitted complete responses (response rate=52.8%). Most programs have absolute contraindications to listing for BMI>45 (adult: 67.5%; pediatric: 88.0%) and age>80 (adult: 55.4%; pediatric: not relevant). Only 29.5% of adult programs and 25.7% of pediatric programs consider HIV seropositivity an absolute contraindication to listing. We found that there is variation in absolute contraindications to listing in adult programs among organ types for BMI>45 (heart 89.8%, lung 92.3%, liver 49.1%, kidney 71.9%), age>80 (heart 83.7%, lung 76.9%, liver 68.4%, kidney 29.2%), and HIV seropositivity (heart 30.6%, lung 59.0%, kidney 16.9%, liver 28.1%).CONCLUSIONS: We argue that variability in listing enhances access to transplantation for potential recipients who have the ability to pursue workup at different centers by allowing different programs to have different risk thresholds. Programs should remain independent in listing practices, but because these practices differ, we recommend transparency in listing policies and informing patients of reasons for listing denial and alternative opportunities to seek listing at another program.
View details for DOI 10.1007/s00268-019-05030-x
View details for PubMedID 31111229
- Why It is Important to Consider Social Support When Assessing Organ Transplant Candidates? The American journal of bioethics : AJOB 2019; 19 (11): 1–8
Validation of the Stanford Proxy Test for Delirium (S-PTD) among critical and noncritical patients.
Journal of psychosomatic research
2018; 114: 8–14
BACKGROUND: The Stanford Proxy Test for Delirium (S-PTD) is a tool developed to be completed by nurses at the end of their shift. It was designed to use the knowledge acquired during a full shift of nurse-patient interaction. The objective of our study was to validate the S-PTD among a mixed sample of patients in both the intensive care unit (ICU) and non-ICU settings.METHODS: A cross-sectional study was conducted in an ICU and three general medical wards in a tertiary care hospital. Patients were independently and blindly assessed for delirium by (1) the patients' primary nurses using the S-PTD at the end of their shift, and (2) a Consultation liaison psychiatrist who conducted a neuropsychiatric evaluation based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).RESULTS: A total 288 patients were included in current analysis. Using the S-PTD, delirium was identified in 72 (25.0%), while an expert neuropsychiatric examination, based on DSM-5 identified delirium in 75 (26.0%) patients. This study demonstrated that the S-PTD has very strong discriminative ability (area under the curve= 0.946, p<0.001). An S-PTD cut-off score ≥3 was associated with an 82.7% sensitivity, an 95.3% specificity, an 86.1% positive predictive value, a 94.0% negative predictive value, and a 92.0% overall diagnostic accuracy. These results were similar in both ICU and general ward patients.CONCLUSION: The S-PTD has excellent sensitivity and specificity in detecting delirium in both ICU and ward patients, even when compared with the gold-standard, a DSM-based neuropsychiatric examination.
View details for PubMedID 30314583
Refining Delirium: A Transtheoretical Model of Delirium Disorder with Preliminary Neurophysiologic Subtypes
AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY
2018; 26 (9): 913–24
The development of delirium indicates neurophysiologic disruption and predicts unfavorable outcomes. This relationship between delirium and its outcomes has inspired a generation of studies aimed at identifying, predicting, and preventing both delirium and its associated sequelae. Despite this, evidence on delirium prevention and management remains limited. No medication is approved for the prevention or treatment of delirium or for its associated psychiatric symptoms. This unmet need for effective delirium treatment calls for a refined approach. First, we explain why a one-size-fits-all approach based on a unitary biological model of delirium has contributed to variance in delirium studies and prevents further advance in the field. Next, in parallel with the shift from dementia to "major neurocognitive disorder," we propose a transtheoretical model of "delirium disorder" composed of interactive elements-precipitant, neurophysiology, delirium phenotype, and associated psychiatric symptoms. We explore how these relate both to the biopsychosocial factors that promote healthy cognition ("procognitive factors") and to consequent neuropathologic sequelae. Finally, we outline a preliminary delirium typology of specific neurophysiologic disturbances. Our model of delirium disorder offers several avenues for novel insights and clinical advance: it univocally differentiates delirium disorder from the phenotype of delirium, highlights delirium neurophysiology as a treatment target, separates the core features of delirium from associated psychiatric symptoms, suggests how procognitive factors influence the core elements of delirium disorder, and makes intuitive predictions about how delirium disorder leads to neuropathologic sequelae and cognitive impairment. Ultimately, this model opens several avenues for modern neuroscience to unravel this disease of antiquity.
View details for PubMedID 30017237
- The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT): A Five-year follow up Prospective Study of Medical & Psychosocial Outcomes PERGAMON-ELSEVIER SCIENCE LTD. 2018: 117
- Psychosocial Contraindications to Transplant Listing Decisions: A National Survey of USA Solid Organ Transplant Programs PERGAMON-ELSEVIER SCIENCE LTD. 2018: 115–16
Medical Contraindications to Solid Organ Transplant Listing: A Survey of Heart, Liver, Lung and Kidney Programs.
WILEY. 2018: 743
View details for Web of Science ID 000431965403060
Legal Status, Criminal History, and Substance Use in Listing Decisions.
WILEY. 2018: 395–96
View details for Web of Science ID 000431965401388
Psychiatric Disorders and Disturbances in Transplant Listing Decisions.
WILEY. 2018: 734–35
View details for Web of Science ID 000431965403036
Mental health assessment of altruistic non-directed kidney donors: An EAPM consensus statement
JOURNAL OF PSYCHOSOMATIC RESEARCH
2018; 107: 26–32
View details for PubMedID 29502760
Transplant Listing Decisions: A National Survey of Adult and Pediatric Heart, Lung, Liver and Kidney Programs
WILEY. 2018: 95
View details for Web of Science ID 000419034500199
Delirium pathophysiology: An updated hypothesis of the etiology of acute brain failure.
International journal of geriatric psychiatry
BACKGROUND: Delirium is the most common neuropsychiatric syndrome encountered by clinicians dealing with older adults and the medically ill and is best characterized by 5 core domains: cognitive deficits, attentional deficits, circadian rhythm dysregulation, emotional dysregulation, and alteration in psychomotor functioning.DESIGN: An extensive literature review and consolidation of published data into a novel interpretation of known pathophysiological causes of delirium.RESULTS: Available data suggest that numerous pathological factors may serve as precipitants for delirium, each having differential effects depending on patient-specific patient physiological characteristics (substrate). On the basis of an extensive literature search, a newly proposed theory, the systems integration failure hypothesis, was developed to bring together the most salient previously described theories, by describing the various contributions from each into a complex web of pathways-highlighting areas of intersection and commonalities and explaining how the variable contribution of these may lead to the development of various cognitive and behavioral dysfunctions characteristic of delirium. The specific cognitive and behavioral manifestations of the specific delirium picture result from a combination of neurotransmitter function and availability, variability in integration and processing of sensory information, motor responses to both external and internal cues, and the degree of breakdown in neuronal network connectivity, hence the term acute brain failure.CONCLUSIONS: The systems integration failure hypothesis attempts to explain how the various proposed delirium pathophysiologic theories interact with each other, causing various clinically observed delirium phenotypes. A better understanding of the underlying pathophysiology of delirium may eventually assist in designing better prevention and management approaches.
View details for PubMedID 29278283
Delirium after lung transplantation: Association with recipient characteristics, hospital resource utilization, and mortality.
2017; 31 (5)
Delirium is associated with increased morbidity and mortality. The factors associated with post-lung transplant delirium and its impact on outcomes are under characterized.The medical records of 163 consecutive adult lung transplant recipients were reviewed for delirium within 5 days (early-onset) and 30 hospital days (ever-onset) post-transplantation. A multivariable logistic regression model assessed factors associated with delirium. Multivariable negative binomial regression and Cox proportional hazards models assessed the association of delirium with ventilator duration, intensive care unit (ICU) length of stay (LOS), hospital LOS and one-year mortality.Thirty six % developed early-onset and 44% - ever-onset delirium. Obesity (OR 6.35, 95% CI 1.61-24.98) and bolused benzodiazepines within the first post-operative day (OR 2.28, 95% CI 1.07-4.89) were associated with early-onset delirium. Early-onset delirium was associated with longer adjusted mechanical ventilation duration (p=0.001), ICU LOS (p<0.001), and hospital LOS (p=0.005). Ever-onset delirium was associated with longer ICU (p<0.001) and hospital LOS (p<0.001). After adjusting for clinical variables, delirium was not significantly associated with one-year mortality (early-onset HR 1.65, 95% CI 0.67-4.03; ever-onset HR 1.70, 95% CI 0.63-4.55).Delirium is common after lung transplant surgery and associated with increased hospital resources. This article is protected by copyright. All rights reserved.
View details for DOI 10.1111/ctr.12966
View details for PubMedID 28314081
Psychiatric Aspects of Critical Care Medicine: Update.
Critical care clinics
2017; 33 (3): xiii-xv
View details for PubMedID 28601144
The intensive care delirium research agenda: a multinational, interprofessional perspective.
Intensive care medicine
Delirium, a prevalent organ dysfunction in critically ill patients, is independently associated with increased morbidity. This last decade has witnessed an exponential growth in delirium research in hospitalized patients, including those critically ill, and this research has highlighted that delirium needs to be better understood mechanistically to help foster research that will ultimately lead to its prevention and treatment. In this invited, evidence-based paper, a multinational and interprofessional group of clinicians and researchers from within the fields of critical care medicine, psychiatry, pediatrics, anesthesiology, geriatrics, surgery, neurology, nursing, pharmacy, and the neurosciences sought to address five questions: (1) What is the current standard of care in managing ICU delirium? (2) What have been the major recent advances in delirium research and care? (3) What are the common delirium beliefs that have been challenged by recent trials? (4) What are the remaining areas of uncertainty in delirium research? (5) What are some of the top study areas/trials to be done in the next 10 years? Herein, we briefly review the epidemiology of delirium, the current best practices for management of critically ill patients at risk for delirium or experiencing delirium, identify recent advances in our understanding of delirium as well as gaps in knowledge, and discuss research opportunities and barriers to implementation, with the goal of promoting an integrated research agenda.
View details for PubMedID 28612089
Acute Brain Failure: Pathophysiology, Diagnosis, Management, and Sequelae of Delirium.
Critical care clinics
2017; 33 (3): 461–519
Delirium is the most common psychiatric syndrome found in the general hospital setting, with an incidence as high as 87% in the acute care setting. Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances. The development of delirium is associated with increased morbidity, mortality, cost of care, hospital-acquired complications, placement in specialized intermediate and long-term care facilities, slower rate of recovery, poor functional and cognitive recovery, decreased quality of life, and prolonged hospital stays. This article discusses the epidemiology, known etiological factors, presentation and characteristics, prevention, management, and impact of delirium.
View details for PubMedID 28601132
Novel Algorithms for the Prophylaxis and Management of Alcohol Withdrawal Syndromes-Beyond Benzodiazepines.
Critical care clinics
2017; 33 (3): 559–99
Benzodiazepine (BZDP) agents are the standard for the prophylaxis and treatment of all phases of alcohol withdrawal syndrome. However, BZDPs have their drawbacks: cognitive impairment, significant neurologic and medical side effects. There are data suggesting that the alcohol recidivism rate and abuse potential is higher for BZDPs treated patients, compared to alternatives. Clinical and research data demonstrate the efficacy and safety of various pharmacologic alternatives to benzodiazepines for the prevention and management of AWS. This article examines the available published evidence regarding the use of non-BZDP agents compared with conventional treatment modalities. The author's BZDP-sparing protocol is highlighted.
View details for PubMedID 28601135
Frontal Lobe Epilepsy: A Primer for Psychiatrists and a Systematic Review of Psychiatric Manifestations.
2016; 57 (5): 445-464
Frontal lobe epilepsy (FLE) can masquerade as a primary psychiatric condition, be misdiagnosed in-lieu of a true psychiatric disorder, or may be comorbid with psychiatric illness.To (1) qualitatively review psychiatric manifestations of FLE and (2) to systematically review the cases/case series of psychiatric manifestations of FLE presented in the literature to date.A systematic review of the literature was performed following the PRISMA guidelines and using PubMed/Medline, PsychInfo, and Cochrane database of systematic reviews to identify cases and case series of psychiatric manifestations of FLE.A total of 35 separate articles were identified. Further, 17 patients primarily presented with psychosis, 33 with affective symptoms, and 16 with personality changes. Also, 62% of cases were males and 38% were females. Ages ranged from 2-83 years with the average age of 32.7. Prior psychiatric history was reported in 27.3% of cases. Causes of seizure were known in 53%, with the most common causes being dysplasia and tumor. Only 6 cases (<10%) did not have electroencephalographic correlations. Psychiatric manifestations were primarily ictal in 74.3% of the cases. Associated manifestations included motor (63.6%), cognitive (34.8%), and medical (9.0%) findings. Surgery was required in 31.8% of the cases, whereas others were treated with medications alone. All, but 3, patients were seizure free and saw an improvement in symptoms with treatment.Given the complexity and multifunctionality of the frontal lobes, FLE can present with complex, psychiatric manifestations, with associated motor, cognitive, and medical changes; thus, psychiatrists should keep FLE on the differential diagnosis of complex neuropsychiatric cases.
View details for DOI 10.1016/j.psym.2016.05.005
View details for PubMedID 27494984
- Suicide Risk Assessment and Management Clinical Manual of Emergency Psychiatry edited by Riba, M., Ravindranath, D., Winder, G. S. American Psychiatric Press Inc. 2016; Second
- Delirium: Prevention and Management Protocols in Critical Care edited by Rodriguez-Villar, S. Marban. 2016; Third: 930–956
Valproic Acid for Treatment of Hyperactive or Mixed Delirium: Rationale and Literature Review
2015; 56 (6): 615-625
Delirium is the most often encountered psychiatric diagnosis in the general hospital, with an incidence of up to 82% in the intensive care unit setting and with significant detrimental effects on patients' morbidity and mortality. Antipsychotics are often considered the first-line pharmacological treatment of delirium, but their use may be limited by lack of efficacy, existing contraindications (e.g., prolonged QTc intervals), or resulting side effects (e.g., akathisia). Valproic acid (VPA) is a potential alternative or adjunct treatment. It has multiple mechanisms of action, including effects on neurotransmitter modulation, neuroinflammation, oxidative stress, and transcription, all of which are implicated in the pathophysiology of delirium. Yet, data on the use of this agent in delirium are limited.In this article, we discuss postulated mechanisms of VPA action that provide a theoretical basis for its use in the treatment of hyperactive and mixed type delirium, based on the known and theorized pathophysiology of delirium. We also discuss potential side effects and considerations with use of VPA.VPA has multiple modulatory effects on neurotransmitter systems, inflammation, oxidative stress, and transcriptional changes implicated in pathophysiology of delirium. When carefully chosen, VPA can be an effective and well-tolerated treatment option for the management of hyperactive and mixed type delirium. Randomized controlled trials are needed to establish tolerability and efficacy of VPA for treatment of delirium.
View details for Web of Science ID 000366315400002
View details for PubMedID 26674479
The Stanford Integrated Psychosocial Assessment for Transplantation: A Prospective Study of Medical and Psychosocial Outcomes
2015; 77 (9): 1018-1030
Psychosocial factors may significantly affect post-transplant outcomes. The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) was developed as an assessment tool to enhance the pre-transplant psychosocial evaluation.We identified heart, lung, liver, or kidney transplant recipients assessed with the SIPAT pre-transplantation and transplanted between June 1, 2008, and July 31, 2011, at our institution. We analyzed prospectively accumulated psychosocial and medical outcomes at 1 year of follow-up.217 patients were identified and included in the analysis. The primary outcomes of organ failure and mortality occurred in 12 and 21 patients, respectively, and were not significantly associated with the pre-transplant SIPAT scores. On the other hand, SIPAT scores were significantly correlated with the probability of poor medical and psychosocial outcomes (secondary outcomes). In fact, higher SIPAT scores predicted higher rates of rejection episodes (Spearman ρ = 0.15, 95% 95% confidence interval [CI] = 0.02-0.28, p = .023), medical hospitalizations (ρ = 0.29, 95% CI = 0.16-0.41, p < .001), infection rates (p = .020), psychiatric decompensation (p = .005), and support system failure (area under the curve = 0.70, 95% CI = 0.60-0.79, p < .001). The relationship with nonadherence suggested a trend, but no statistical significance was observed (area under the curve = 0.60, 95% CI = 0.50-0.71, p = .058).Study outcomes suggest that SIPAT is a promising pre-transplantation assessment tool that helps identify candidate's areas of psychosocial vulnerability and whose scores are associated with both psychosocial and medical outcomes after transplantation.
View details for DOI 10.1097/PSY.0000000000000241
View details for PubMedID 26517474
Adjunctive Valproic Acid in Management-Refractory Hyperactive Delirium: A Case Series and Rationale.
journal of neuropsychiatry and clinical neurosciences
2015; 27 (4): 365-370
Patients with delirium may fail to respond to standard therapies. Sixteen patients with management-refractory hyperactive delirium responded to adjunctive valproic acid, with complete resolution of hyperactive delirium in 13 cases. A rationale for using valproic acid in such circumstances is discussed.
View details for DOI 10.1176/appi.neuropsych.14080190
View details for PubMedID 25803136
Prospective Validation Study of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) in Medically Ill Inpatients: A New Scale for the Prediction of Complicated Alcohol Withdrawal Syndrome
ALCOHOL AND ALCOHOLISM
2015; 50 (5): 509-518
The prevalence of alcohol use disorders (AUDs) among hospitalized medically ill patients exceeds 40%. Most AUD patients experience uncomplicated alcohol withdrawal syndrome (AWS), requiring only supportive medical intervention, while complicated AWS occurs in up to 20% of cases (i.e. seizures, delirium tremens). We aimed to prospectively test and validate the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), a new tool to identify patients at risk for developing complicated AWS, in medically ill hospitalized patients.We prospectively considered all subjects hospitalized to selected general medicine and surgery units over a 12-month period. Participants were assessed independently and blindly on a daily basis with PAWSS, Clinical Institute Withdrawal Assessment-Alcohol, Revised (CIWA-Ar) and clinical monitoring throughout their admission to determine the presence and severity of AWS.Four hundred and three patients were enrolled in the study. Patients were grouped by PAWSS score: Group A (PAWSS < 4; considered at low risk for complicated AWS); Group B (PAWSS ≥ 4; considered at high risk for complicated AWS). The results of this study suggest that, using a PAWSS cutoff of 4, the tool's sensitivity for identifying complicated AWS is 93.1% (95%CI[77.2, 99.2%]), specificity is 99.5% (95%CI[98.1, 99.9%]), positive predictive value is 93.1% and negative predictive value is 99.5%; and has excellent inter-rater reliability with Lin's concordance coefficient of 0.963 (95% CI [0.936, 0.979]).PAWSS has excellent psychometric characteristics and predictive value among medically ill hospitalized patients, helping clinicians identify those at risk for complicated AWS and allowing for prevention and timely treatment of complicated AWS.
View details for DOI 10.1093/alcalc/agv043
View details for Web of Science ID 000363934400004
View details for PubMedID 25999438
Prolonged neuropsychiatric effects following management of chloroquine intoxication with psychotropic polypharmacy.
Clinical case reports
2015; 3 (6): 379-387
Susceptibility to quinoline antimalarial intoxication may reflect individual genetic and drug-induced variation in neuropharmacokinetics. In this report, we describe a case of chloroquine intoxication that appeared to be prolonged by subsequent use of multiple psychotropic medications. This case highlights important new considerations for the management of quinoline antimalarial intoxication.
View details for DOI 10.1002/ccr3.238
View details for PubMedID 26185633
The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT): A Two-Year Follow-Up of a Prospective Study of Medical & Psychosocial Outcomes
35th Annual Meeting and Scientific Sessions of the International-Society-for-Heart-and-Lung-Transplantation
ELSEVIER SCIENCE INC. 2015: S174–S174
View details for Web of Science ID 000353251500449
- Acute Brain Failure: Identification & Management Handbook of Consultation-Liaison Psychiatry edited by Leigh, H., Streltzer, J. Springer. 2015; Second: 157–188
- Delirium Psychiatric Care of the Medical Patient edited by Fogel, B., Greenberg, D. Oxford University Press. 2015; Third
- Hypnosis in Psychosomatic Medicine Psychiatric Care of the Medical Patient edited by Fogel, B., Greenberg, D. Oxford University Press. 2015; Third
- An Insatiable Desire for Tofu: A Case of Restless Legs and Unusual Pica in Iron Deficiency Anemia PSYCHOSOMATICS 2014; 55 (6): 680-685
The DSM-5 criteria, level of arousal and delirium diagnosis: inclusiveness is safer.
2014; 12: 141-?
Delirium is a common and serious problem among acutely unwell persons. Although linked to higher rates of mortality, institutionalisation and dementia, it remains underdiagnosed. Careful consideration of its phenomenology is warranted to improve detection and therefore mitigate some of its clinical impact. The publication of the fifth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5) provides an opportunity to examine the constructs underlying delirium as a clinical entity.Altered consciousness has been regarded as a core feature of delirium; the fact that consciousness itself should be physiologically disrupted due to acute illness attests to its clinical urgency. DSM-5 now operationalises 'consciousness' as 'changes in attention'. It should be recognised that attention relates to content of consciousness, but arousal corresponds to level of consciousness. Reduced arousal is also associated with adverse outcomes. Attention and arousal are hierarchically related; level of arousal must be sufficient before attention can be reasonably tested.Our conceptualisation of delirium must extend beyond what can be assessed through cognitive testing (attention) and accept that altered arousal is fundamental. Understanding the DSM-5 criteria explicitly in this way offers the most inclusive and clinically safe interpretation.
View details for DOI 10.1186/s12916-014-0141-2
View details for PubMedID 25300023
View details for PubMedCentralID PMC4177077
The "Prediction of Alcohol Withdrawal Severity Scale" (PAWSS): Systematic literature review and pilot study of a new scale for the prediction of complicated alcohol withdrawal syndrome.
2014; 48 (4): 375-390
To date, no screening tools for alcohol withdrawal syndromes (AWS) have been validated in the medically ill. Although several tools quantify the severity of AWS (e.g., Clinical Institute Withdrawal Assessment for Alcohol [CIWA]), none identify subjects at risk of AWS, thus missing the opportunity for timely prophylaxis. Moreover, there are no validated tools for the prediction of complicated (i.e., moderate to severe) AWS in the medically ill.Our goals were (1) to conduct a systematic review of the published literature on AWS to identify clinical factors associated with the development of AWS, (2) to use the identified factors to develop a tool for the prediction of alcohol withdrawal among patients at risk, and (3) to conduct a pilot study to assess the validity of the tool.For the creation of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), we conducted a systematic literature search using PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines for clinical factors associated with the development of AWS, using PubMed, PsychInfo, MEDLINE, and Cochrane Databases. Eligibility criteria included: (i) manuscripts dealing with human subjects, age 18 years or older, (ii) manuscripts directly addressing descriptions of AWS or its predisposing factors, including case reports, naturalistic case descriptions, and all types of clinical trials (e.g., randomized, single-blind, or open label studies), (iii) manuscripts describing characteristics of alcohol use disorder (AUD), and (iv) manuscripts dealing with animal data (which were considered only if they directly dealt with variables described in humans). Obtained data were used to develop the Prediction of Alcohol Withdrawal Severity Scale, in order to assist in the identification of patients at risk for complicated AWS. A pilot study was conducted to assess the new tool's psychometric qualities on patients admitted to a general inpatient medicine unit over a 2-week period, who agreed to participate in the study. Blind to PAWSS results, a separate group of researchers retrospectively examined the medical records for evidence of AWS.The search produced 2802 articles describing factors potentially associated with increased risk for AWS, increased severity of withdrawal symptoms, and potential characteristics differentiating subjects with various forms of AWS. Of these, 446 articles met inclusion criteria and underwent further scrutiny, yielding a total of 233 unique articles describing factors predictive of AWS. A total of 10 items were identified as correlated with complicated AWS (i.e., withdrawal hallucinosis, withdrawal-related seizures, and delirium tremens) and used to construct the PAWSS. During the pilot study, a total of 68 subjects underwent evaluation with PAWSS. In this pilot sample the sensitivity, specificity, and positive and negative predictive values of PAWSS were 100%, using the threshold score of 4.The results of the literature search identified 10 items which may be correlated with risk for complicated AWS. These items were assembled into a tool to assist in the identification of patients at risk: PAWSS. The results of this pilot study suggest that PAWSS may be useful in identifying risk of complicated AWS in medically ill, hospitalized individuals. PAWSS is the first validated tool for the prediction of severe AWS in the medically ill and its use may aid in the early identification of patients at risk for complicated AWS, allowing for prophylaxis against AWS before severe alcohol withdrawal syndromes develop.
View details for DOI 10.1016/j.alcohol.2014.01.004
View details for PubMedID 24657098
- Dissociative Disorders Psychiatry edited by Tasman, A., Lieberman, J., Riba, M. Wiley. 2014; Fourth
- Dementia: Diagnosis & Management Handbook of Consultation-Liaison Psychiatry edited by Leigh, H., Streltzer, J. Springer. 2014; Second
- Hypnosis Psychiatry edited by Tasmana, A., Kay, J., Lieberman, J., First, M., Riba, M. Wiley. 2014; Fourth
Neuropathogenesis of Delirium: Review of Current Etiologic Theories and Common Pathways.
American journal of geriatric psychiatry
2013; 21 (12): 1190-1222
Delirium is a neurobehavioral syndrome caused by dysregulation of neuronal activity secondary to systemic disturbances. Over time, a number of theories have been proposed in an attempt to explain the processes leading to the development of delirium. Each proposed theory has focused on a specific mechanism or pathologic process (e.g., dopamine excess or acetylcholine deficiency theories), observational and experiential evidence (e.g., sleep deprivation, aging), or empirical data (e.g., specific pharmacologic agents' association with postoperative delirium, intraoperative hypoxia). This article represents a review of published literature and summarizes the top seven proposed theories and their interrelation. This review includes the "neuroinflammatory," "neuronal aging," "oxidative stress," "neurotransmitter deficiency," "neuroendocrine," "diurnal dysregulation," and "network disconnectivity" hypotheses. Most of these theories are complementary, rather than competing, with many areas of intersection and reciprocal influence. The literature suggests that many factors or mechanisms included in these theories lead to a final common outcome associated with an alteration in neurotransmitter synthesis, function, and/or availability that mediates the complex behavioral and cognitive changes observed in delirium. In general, the most commonly described neurotransmitter changes associated with delirium include deficiencies in acetylcholine and/or melatonin availability; excess in dopamine, norepinephrine, and/or glutamate release; and variable alterations (e.g., either a decreased or increased activity, depending on delirium presentation and cause) in serotonin, histamine, and/or γ-aminobutyric acid. In the end, it is unlikely that any one of these theories is fully capable of explaining the etiology or phenomenologic manifestations of delirium but rather that two or more of these, if not all, act together to lead to the biochemical derangement and, ultimately, to the complex cognitive and behavioral changes characteristic of delirium.
View details for DOI 10.1016/j.jagp.2013.09.005
View details for PubMedID 24206937
Broken Heart Syndrome (Takotsubo Cardiomyopathy) Triggered by Acute Mania: A Review and Case Report
2013; 54 (1): 74-79
View details for PubMedID 22795622
Benzodiazepine loading versus symptom-triggered treatment of alcohol withdrawal: a prospective, randomized clinical trial
GENERAL HOSPITAL PSYCHIATRY
2012; 34 (6): 611-617
The objectives were to compare the efficacy of a benzodiazepine loading versus a symptom-triggered protocol in the management of alcohol withdrawal.We conducted a prospective, randomized, controlled trial including 47 consecutive patients admitted to one of two tertiary care medical centers who developed alcohol withdrawal syndrome. Patients were randomly assigned to either a benzodiazepine loading protocol or a symptom-triggered treatment protocol. The Clinical Institute Withdrawal Assessment for Alcohol-Revised scale (CIWA-Ar) was recorded throughout the length of stay, along with measures of autonomic system functioning.The average rate of change of CIWA-Ar scores was -1.5 ± 1.3 for the symptom-triggered group and -2.3 ± 2.5 for the loading group. Average rate of change for systolic blood pressure was -2.7 ± 5.3 for the symptom-triggered group and -2.3 ± 6.4 for the loading group. There was no significant difference between the rates of change for either group on either measure. Similarly, there was no significant difference in total benzodiazepine use between groups. Within 72 h of treatment, 69.6% of patients in the loading group were free of withdrawal symptoms versus 41.7% in the symptom-triggered group, a difference not reaching statistical significance.This study did not reveal clear evidence of a clinical advantage for choosing either treatment method.
View details for DOI 10.1016/j.genhosppsych.2012.06.016
View details for Web of Science ID 000310672100005
View details for PubMedID 22898443
The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT): A New Tool for the Psychosocial Evaluation of Pre-Transplant Candidates
2012; 53 (2): 123-132
While medical criteria have been well established for each end-organ system, psychosocial listing criteria are less standardized. To address this limitation, we developed and tested a new assessment tool: the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT).The SIPAT was developed from a comprehensive review of the literature on the psychosocial factors that impact transplant outcomes. Five examiners blindly applied the SIPAT to 102 randomly selected transplant cases, including liver, heart, and lung patients. After all subject's files had been rated by the examiners, the respective transplant teams provided the research team with the patient's outcome data.Univariate logistic regression models were fit in order to predict the transplant psychosocial outcome (positive or negative) using each rater's SIPAT scores. These results show that SIPAT scores are highly predictive of the transplant psychosocial outcome (P < 0.0001). The instrument has excellent inter-rater reliability (Pearson's correlation coefficient = 0.853), even among novice raters.The SIPAT is a comprehensive screening tool to assist in the psychosocial assessment of organ transplant candidates. Its strengths includes the standardization of the evaluation process and its ability to identify subjects who are at risk for negative outcomes after the transplant, in order to allow for the development of interventions directed at improving the patient's candidacy. Our goal is that the SIPAT, in addition to a set of agreed upon minimal psychosocial listing criteria, would be used in combination with organ-specific medical listing criteria in order to establish standardized criteria for the selection of transplant recipients.
View details for PubMedID 22424160
Empirical findings on legal difficulties among practicing psychiatrists
ANNALS OF CLINICAL PSYCHIATRY
2011; 23 (4): 297-307
This article reviews the published literature on areas of legal difficulty among practicing psychiatrists.A literature search using PubMed identified studies of malpractice lawsuits or medical board discipline of psychiatrists between 1990 and 2009. Eight studies of physician discipline in the United States and one from the United Kingdom were identified. Information from 3 insurance companies and 3 sets of aggregated insurance company data also were available. One follow-up study of hospitalized psychiatric patients also was reviewed.Studies of medical board discipline indicate that, compared with other specialties, psychiatrists are at an increased risk of disciplinary action. Psychiatrists who were female, board certified, and in practice for a short period of time had a lower chance of medical board discipline. Psychiatry claims accounted for a very small proportion of overall malpractice claims and settlements. The amount of patient disability secondary to alleged malpractice was the most important variable predicting insurance payout.Psychiatrists appear to be disciplined by medical boards at an above-average frequency compared with other medical specialties. However, few malpractice suits reach the courts, and psychiatry represents a very small proportion of overall physician malpractice claims and dollars of settlement.
View details for Web of Science ID 000297034500009
View details for PubMedID 22073387
An Approach to the Patient with Substance Use and Abuse
MEDICAL CLINICS OF NORTH AMERICA
2010; 94 (6): 1169-?
Substance use is ubiquitous among medically ill patients. The 2008 National Survey on Drug Abuse and Health survey estimated that 20.1 million Americans aged 12 years or older (8% of the US population) had used an illicit drug during the preceding month. Some licit substances also create havoc. The survey found that slightly more than half (56%) of Americans reported being current drinkers of alcohol. A total of 6.2 million (2.5%) Americans used prescription-type psychotherapeutic drugs for nonmedical purposes and 70.9 million Americans (or 28.4%) used tobacco during the survey period. Substance abuse problems were diagnosed in up to 36% of medically hospitalized patients for whom a psychiatric consultation was requested. Given how prevalent the use of substances is among the medically ill and their potential effect on comorbid medical conditions, it is important for physicians to be mindful of their prevalence and presentation. This article covers the presenting symptoms of intoxication and withdrawal states, addresses the acute management of the most commonly encountered substances, and summarizes all others in a table.
View details for DOI 10.1016/j.mcna.2010.08.010
View details for Web of Science ID 000284079600009
View details for PubMedID 20951277
Post-traumatic stress disorder (PTSD) is not a contraindication to gastric bypass in veterans with morbid obesity
SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES
2010; 24 (8): 1892-1897
The veteran population is routinely screened for post-traumatic stress disorder (PTSD). The prevalence of obesity in this population continues to increase. We examined whether weight loss outcomes in veterans with PTSD is comparable to results in veterans who do not suffer from PTSD, after gastric bypass. We also examined the effect of bariatric surgery on PTSD symptoms.This retrospective review of prospective data compares veterans with and without PTSD who underwent laparoscopic gastric bypass. Differences between the means of age, initial BMI, and percent excess weight loss were compared between the groups using a Student's t test. Pearson's chi(2) was used to evaluate the relationship between a diagnosis of PTSD, major depressive disorder (MDD), and other Axis I psychiatric disorders. A similar analysis was done to assess for a relationship between PTSD and obesity-related comorbidities, including diabetes mellitus (DM), hypertension (HTN), hyperlipidemia, and GERD.We identified 24 patients who had gastric bypass and a diagnosis of PTSD before surgery and compared them to those without PTSD. Both groups had a similar mean age and initial BMI. There was no significant difference between the percent excess weight lost after 1 year follow-up between the PTSD group (66%) and the non-PTSD group (72%) (p = 0.102). In assessing comorbid conditions, we found a significant association between the diagnosis of PTSD and MDD (p = 0.002), PTSD and other Axis I disorders (p = 0.004), and PTSD and GERD (p = 0.002). However, we saw no significant association between PTSD and DM (p = 0.977), HTN (p = 0.332), and obstructive sleep apnea (OSA) (p = 0.676). The severity of PTSD symptoms fluctuated in the postoperative period.Veterans with PTSD have comparable weight loss to those without PTSD after gastric bypass. In addition, surgery does not seem to have an adverse effect on PTSD symptoms, although PTSD symptomatology tends to fluctuate over time. Further study in this patient population is warranted.
View details for DOI 10.1007/s00464-009-0866-8
View details for Web of Science ID 000279488400015
View details for PubMedID 20063014
The Impact of Depression in Heart Disease
CURRENT PSYCHIATRY REPORTS
2010; 12 (3): 255-264
Depression and heart disease affect millions of people worldwide. Studies have shown that depression is a significant risk factor for new heart disease and that it increases morbidity and mortality in established heart disease. Many hypothesized and studied mechanisms have linked depression and heart disease, including serotonergic pathway and platelet dysfunction, inflammation, autonomic nervous system and hypothalamic-pituitary-adrenal axis imbalance, and psychosocial factors. Although the treatment of depression in cardiac patients has been shown to be safe and modestly efficacious, it has yet to translate into reduced cardiovascular morbidity and mortality. Understanding the impact and mechanisms behind the association of depression and heart disease may allow for the development of treatments aimed at altering the devastating consequences caused by these comorbid illnesses.
View details for DOI 10.1007/s11920-010-0116-8
View details for Web of Science ID 000289731700015
View details for PubMedID 20425289
- Current approaches to the recognition and treatment of alcohol withdrawal and delirium tremens: "old wine in new bottles" or "new wine in old bottles". Primary care companion to the Journal of clinical psychiatry 2010; 12 (3)
Dexmedetomidine and the Reduction of Postoperative Delirium after Cardiac Surgery
2009; 50 (3): 206-217
Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances.The authors investigated the effects of postoperative sedation on the development of delirium in patients undergoing cardiac-valve procedures.Patients underwent elective cardiac surgery with a standardized intraoperative anesthesia protocol, followed by random assignment to one of three postoperative sedation protocols: dexmedetomidine, propofol, or midazolam.The incidence of delirium for patients receiving dexmedetomidine was 3%, for those receiving propofol was 50%, and for patients receiving midazolam, 50%. Patients who developed postoperative delirium experienced significantly longer intensive-care stays and longer total hospitalization.The findings of this open-label, randomized clinical investigation suggest that postoperative sedation with dexmedetomidine was associated with significantly lower rates of postoperative delirium and lower care costs.
View details for Web of Science ID 000267537700004
View details for PubMedID 19567759
- Aspects to consider when evaluating a live organ donor Focus: The Journal of Lifelong Learning in Psychiatry 2009; VII (3)
- Delirium risk factors and treatment algorithm Focus: The Journal of Lifelong Learning in Psychiatry 2009; VII (3)
Pathoetiological Model of Delirium: a Comprehensive Understanding of the Neurobiology of Delirium and an Evidence-Based Approach to Prevention and Treatment
20th United States Psychiatric and Mental Health Congress
W B SAUNDERS CO-ELSEVIER INC. 2008: 789-?
Delirium is the most common complication found in the general hospital setting. Yet, we know relatively little about its actual pathophysiology. This article contains a summary of what we know to date and how different proposed intrinsic and external factors may work together or by themselves to elicit the cascade of neurochemical events that leads to the development delirium. Given how devastating delirium can be, it is imperative that we better understand the causes and underlying pathophysiology. Elaborating a pathoetiology-based cohesive model to better grasp the basic mechanisms that mediate this syndrome will serve clinicians well in aspiring to find ways to correct these cascades, instituting rational treatment modalities, and developing effective preventive techniques.
View details for DOI 10.1016/j.ccc.2008.06.004
View details for Web of Science ID 000260863000007
View details for PubMedID 18929943
Delirium following abrupt discontinuation of fluoxetine
CLINICAL NEUROLOGY AND NEUROSURGERY
2008; 110 (1): 69-70
Sudden discontinuation of serotonin reuptake inhibitors (SRI) can lead to a number of psychological (e.g., nervousness, anxiety, crying spells, psychomotor agitation, irritability, depersonalization, decreased mood, memory disturbances, confusion, decreased concentration, and/or slowed thinking) and somatic (e.g., nausea, dizziness, headache) symptoms. Recent studies have shown that withdrawal symptoms are common with paroxetine, venlafaxine and fluvoxamine, but relatively rare and mild with fluoxetine cessation, likely as a result of its longer half-life. We report an unusual case of a patient who developed delirium after abrupt discontinuation of fluoxetine.
View details for DOI 10.1016/j.clineuro.2007.08.016
View details for Web of Science ID 000252799500013
View details for PubMedID 17913343
- Pathoetiological model of delirium: a comprehensive understanding of the neurobiology of delirium and an evidence-based approach to prevention and treatment. Crit Care Clin 2008; 24 (4): 789-856
- Delirium in the acute care setting: characteristics, diagnosis and treatment. Crit Care Clin. 2008; 24 (4): 657-722
- Antidepressant and statin interactions: A review and case report of simvastatin and nefazodone-induced rhabdomyolysis and transaminitis PSYCHOSOMATICS 2005; 46 (6): 565-568
Social support and maladaptive coping as predictors of the change in physical health symptoms among persons living with HIV/AIDS
AIDS PATIENT CARE AND STDS
2005; 19 (9): 587-598
This study examined social support and maladaptive coping as predictors of HIV-related health symptoms. Sixty-five men and women living with HIV/AIDS completed baseline measures assessing coping strategies, social support, and HIV-related health symptoms. The sample was primarily low-income and diverse with respect to gender, ethnicity, and sexual orientation. Three, 6, and 12 months after completing baseline assessments, physical health symptoms associated with HIV disease were assessed. After controlling for demographic characteristics, CD4 T-cell count, and baseline HIV-related health symptoms, individuals reporting lower increase in HIV-related health symptoms used less venting (expressing emotional distress) as a strategy for coping with HIV. However, when satisfaction with social support was added to the model, the use of this coping strategy was no longer significant, and individuals reporting more satisfying social support were more likely to report lower increase in their HIV-related health symptoms, suggesting that social support is a robust predictor of health outcomes over time independent of coping style and baseline medical status. These findings provide further evidence that social support can buffer deleterious health outcomes among individuals with a chronic illness. Future research needs to examine mediating pathways that can explain this relationship.
View details for Web of Science ID 000232058300006
View details for PubMedID 16164385
- Differences between long- and short-acting benzodiazepines in the management of alcohol withdrawal J Psychosomatic Research 2005; 58: S61
- Alpha-2 agonist induced sedation prevents ICU delirium in post-cardotomy patients J Psychosomatic Research 2005; 58: S61
- Dissociative States in Personality Disorders Textbook of Personality Disorders; Oldham JM, Skodol AE, Bender DS (eds) 2005: 493-521
- Dexmedetomidine: can it reduce the incidence of ICU delirium? Psychosomatics 2004; 45 (2): 173
- Post-Operative Sedation and the Incidence of Delirium and Cognitive Deficits in Cardiac Surgery Patients Anesthesiology 2003; 99: 465
- Evidence of decreased incidence of extra-pyramidal symptoms with intravenous haloperidol J Psychosom Research 2003; 55: 140-141
- Selective attention as possible mechanism of symptom production in conversion disorders J Psychosom Research 2003; 55: 140
- Hypnosis Psychiatry, Second Edition; Tashman A, Kay J, Lieberman J (eds) 2003: 1807-1837
- Dissociative Disorders Psychiatry; Tashman A, Kay J, Lieberman J (eds) 2003: 1452-1470
- Clinical implications of the recognition and management of delirium in general medical and surgical wards Psychosomatics 2003; 44 (2): 157-158
- Predictors of quality of life in HIV-infected individuals: the effects of immunological status and depression J Psychosom Research 2003; 55: 140
- Recognition and management of delirium in the medical and surgical intensive care wards J Psychosom Research 2003; 55 (2): 150
- Postoperative sedation and the incidence of delirium and cognitive deficits in cardiac surgery patients Annals of Neurology 2003; 54: S27-28
- Ethical and psychosocial challenges in liver transplantation J Psychosom Research 2003; 55: 116
- Liver Transplantation in alcoholic liver disease: selection and outcome J Psychosom Research 2003; 55: 115-116
- Clinical and Financial Implications of the Timely Recognition and Management of Delirium in the Acute Medical Wards J Psychosom Research 2003; 55 (2): 151
- The role of the novel anesthetic agent dexmedetomidine on reduction of the incidence of ICU delirium in postcardiotomy patients J Psychosom Research 2003; 55 (2): 150
- Factitious Disorder-By-Proxy: when parents deceive their children?s doctors American Journal of Forensic Psychiatry 2003; 24 (1): 1-22
- Ethical and clinical implications of liver transplantation in patients on methadone maintenance therapy J Psychosom Research 2003; 55: 116
- Clinical characteristics, pathophysiology, and treatment of Conversion Disorders: A research based approach Psychosomatics 2003; 44 (2): 165
- Psychosomatic aspects in liver disease J Psychosom Research 2003; 55: 115
Acute stress reactions following the assassination of Mexican presidential candidate Colosio
13th Annual Meeting of the International-Society-for-Traumatic-Stress-Studies
JOHN WILEY & SONS INC. 2002: 401–5
Considerable evidence suggests that exposure to traumatic events increases the risk of developing anxiety-spectrum disorders in response to later traumatization. We conducted a survey in Guadalajara, Mexico to assess factors associated with acute stress reactions to the assassination of a political figure. Participants included 86 adults who completed the Stanford Acute Stress Reaction Questionnaire (SASRQ) and measures of the perceived impact of the assassination, exhibited emotional behavior following the assassination, and had exposure to a specific prior disaster (a gas pipeline explosion). The results suggest that acute stress reactions can occur in response to an assassination, and that those most susceptible are those most emotionally invested, those who engage in emotional behavioral responses, and those whose lives have been affected by a previous potentially traumatic event.
View details for Web of Science ID 000177968900008
View details for PubMedID 12392228
- Dissociative Disorders Textbook of Psychiatry, Fourth Edition; Talbot J, Yudosky S (Eds.) 2002: 709-742
- When patients deceive doctors: a review of Factitious Disorders American Journal of Forensic Psychiatry 2002; 23 (2): 29-58
- Hypnosis Textbook of Psychiatry, Fourth Edition; Talbot J, Yudosky S (Eds.) 2002: 1461-1516
Performance improvement: increasing recognition and treatment of postoperative delirium.
Progress in cardiovascular nursing
2000; 15 (3): 114-115
View details for PubMedID 10951955
- Conversion Disorder Review of Psychiatry-Volume 20: Somatoform and Factitious Disorders; Phillips KA (Ed.) 2000: 95-128
- Intravenous versus oral haloperidol: An evaluation of the incidence of extra-pyramidal symptoms Psychosomatics 2000; 41 (2): 169-170
- Treatment of Dissociative Disorders A Guide to Treatments That Work, 2nd Edition; Nathan PE, Gorman JM (Eds.) 2000: 463-496
- Dissociation Encyclopedia of Stress; Fink G (Ed) 2000: 714-722
- Immunological status versus depression as predictors of quality of life in HIV-infected individuals Immunological status versus depression as predictors of quality of life in HIV-infected individuals 2000; 41 (2): 186
- Medical Hypnosis Psychiatric Care of the Medical Patient.; Stoudemire A (Ed) 2000: 73-90
- The Relationship Between Pain and Coping Styles Among HIV-Positive Men and Women Psychology and Health 2000; 15: 869-879
- Hypnosis Effective Treatments for PTSD; Foa EB, Keane TM, Friedman MJ (Eds.) 2000: 247-279
The relationship between pain and coping styles among HIV-positive men and women
PSYCHOLOGY & HEALTH
2000; 15 (6): 869-879
View details for Web of Science ID 000165761600011
Diagnoses of children and adolescents on initial presentation to a Nigerian outpatient psychiatry clinic
INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY
1999; 45 (3): 190-197
Child and adolescent psychiatry is an underdeveloped specialty in Nigeria, relegated by more entrenched cultural systems, such as traditional healers and syncretic churches, to merely an auxiliary role in child mental health care. Little is therefore known about the epidemiology of childhood disorders as encountered in psychiatric settings. We reviewed the outpatient psychiatric clinic's patient register at the Psychiatric Hospital of Uselu in Benin City, Nigeria, over a twenty-four week period. Fifty-three patients who presented in the twenty-four week index period had definite diagnoses indicated in the register. Of these, 68% had diagnoses denoting significant behavioral disturbances that would motivate their visit to allopathic hospitals after other, more culturally sanctioned healers were of little help. Our findings are compared with similar studies in other cultures.
View details for Web of Science ID 000083061600006
View details for PubMedID 10576085
- Dissociative Disorders Textbook of Psychiatry; Talbot J, Yudosky S 1999: 711-738
- La Hipnosis y los Trastornos Posttraumáticos Anales de Psicologia 1999; 15 (1): 147-155
- Diagnoses of children and adolescents on initial presentation to a Nigerian outpatient psychiatry clinic Inter J Soc Psychiatr 1999; 45 (3): 190-197
- Immunological status vs. depression as predictors of quality of life in HIV-infected individuals Psychosomatics 1999; 40 (2): 160
- Hypnosis Textbook of Psychiatry; Talbot J, Yudosky S (Eds.) 1999: 1243-1247
- Manual of Psychiatric Care in the General Hospital: Assesment Tools and Drug Treatment Recommendations & Protocols. Department of Pharmacy, Stanford Health Services. 1998
- Trauma, Dissociation and Hypnotizability Trauma, Memory and Dissociation; Marmar R, & Bremmer D. (Eds.) 1998: 57-106
- Treatment of Dissociative Disorders A Guide to Treatments That Work; Nathan PE, Gorman JM (Eds.) 1998: 423-446
- Conversion disorder: Are the symptoms the result of pure psychology or true physiological changes? Psychosomatics 1997; 38 (2): 190-191
- Liver transplantation for alcoholic liver disease: selection and outcome. Clinics of North America: Clinics in Liver Disease W.B.Saunders Co. 1997; 1 (2): 305-321,
- Treatment of dissociative disorders in Nathan PE, & Gorman JM (Eds.) A Guide to Treatments That Work. Oxford Press 1997: 423-446
- Hypnosis for Psychiatric Disorders Current Psychiatric Therapy II: Dunner, D (ed) 1996: 600-608
- Hypnosis in Tashman A, Kay J, & Lieberman J. (Eds.) Psychiatry. Philadelphia, PA: W. B. Saunders Company 1996: 1475-1499
- The Psychophysiology of Conversion Disorders Psychosomatics 1996; 37 (2): 216-217
- Hypnosis Psychiatry; Tashman A, Kay J, & Lieberman J. (Eds.) 1996: 1475-1499
- Using Hypnosis Women Molested in Childhood; Classen C. (Ed.) 1995: 163-186
- Treatment of Post Traumatic Stress Disorder Dissociation: Clinical, Theoretical and Research Perspectives; Lynn SJ, & Rhue J. (Eds.) 1994: 215-241