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Psychiatry Newsletter - Integrating Psychiatry and Medicine

Hopkins BrainWise - Winter 2015

Integrating Psychiatry and Medicine

Date: December 10, 2014

Dr. Bienvenu and Dr. Clark
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Psychiatrists Joe Bienvenu and Michael Clark with medicine resident Colin Massey and physician assistant Victoria Gargon in the Johns Hopkins Hospital medical intensive care unit.

The consulting psychiatrists at Johns Hopkins seem to be everywhere. They move through the 1,000-bed hospital interacting with patients who are recovering from surgery, learning to live with chronic illnesses or pain, or dealing with new diagnoses. And, they are increasingly spending time with patients who are not doing well despite the best medical care.

“Mental health and behavioral issues are one of the largest drivers of complications, longer lengths of stay and poor outcomes,” says psychiatrist Michael Clark, who is also vice chair for clinical affairs. “Rather than having the patients come to us, we visit them to evaluate these issues and provide treatment options.”

The goal is to integrate psychiatry with medicine, allowing a seamless delivery for patients whose clinical outcomes are affected by either pre-existing psychiatric or behavioral illnesses or psychiatric issues that develop as a result of their medical diseases.

Visiting pediatric patients in their rooms can be especially important, says pediatric psychiatrist Marco Grados. “Psychiatric illnesses still have a stigma,” he says. “Parents who might not take their children to a psychiatrist may consent to us seeing their children in the pediatric building.”

By visiting with the children and their parents, the pediatric psychiatrists can explain how the stress of long hospital stays interferes with the course of medical illnesses. Grados says that once parents understand this, they are more likely to accept assistance.

Close working relationships between psychiatry and medicine can also lead to changes in treatments. After observing the disturbing effects of heavy sedation on children in critical care settings, psychiatrists are helping the pediatric intensive care unit medical staff change highly sedating medications to other options, such as low-dose neuroleptics when indicated to lessen the confusion and anxiety children experience when they are brought out of sedation.

In some medical situations, it can be difficult to determine whether a disease or a medication is causing a psychiatric issue.

Psychiatrist Joe Bienvenu recalls a case in which a 50-year-old with a history of bipolar disorder and viral hepatitis was transferred to Johns Hopkins because of a second bout with confusion and fever and the development of hyperreflexia and myoclonus. A detailed review of his medical history and his physical signs suggested a diagnosis of serotonin syndrome, and the symptoms resolved quickly with administration of the serotonin blocker cyproheptadine.

Still, not all cases are complex. “Our most common differential diagnosis,” Bienvenu says, “is deciding whether a patient’s sad mood is due to acute brain dysfunction (delirium), whether it is a reaction to demoralizing circumstances, or whether there is a depressive illness.”

Once these possibilities are evaluated, the psychiatrist can recommend an appropriate course of treatment. For many patients, says Bienvenu, nailing this down makes all the difference in their recoveries.

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