CHALLENGES AND

LANDSCAPE FOR
TRANSFORMATION IN
CL PSYCHIATRY
SERVICES
DR. PANKAJ KUMAR
ADDITIONAL PROF AND HOD
AIIMS PATNA
IMPACT OF COVID 19
 PATIENT ISOLATION, MASKING AND DISRUPTED SOCIAL GATHERING
 Increased psychological stress and psychiatric illness affecting both patients and hospital
workers
 High rates of delirium, neuropsychiatric disorders, anxiety, depression, and acute stress
disorder.
 Surveys indicated that 50% or more of physicians and nurses experienced clinically significant
levels of anxiety, depression, and acute stress disorder
 RAPID RISE IN NEED FOR CL PSYCHIATRY SERVICES
LESSONS LEARNT..
 The development of remote work and telepsychiatry : It became evident that telepsychiatry
consultation works well, but a substantial strengthening of logistics is needed; it is necessary
to triage for appropriateness for telepsychiatry consultation
 Support for the wellness of hospital staff: Frontline workers experienced extreme stress during the
pandemic because of
 exceptional workloads,
 difficult treatment decisions,
 risks of becoming infected and of transmission of infection to others, and the
 experience of a high volume of patient deaths.

 Components of health care worker stress during the pandemic include increased tension between work
and home family- self-care obligations, moral injury and grief, uncertainty, loss of trust in systems,
career disruption, and changing clinical roles.

Shapiro et al, 2021

LESSONS LEARNT..
 Support for the wellness of CL psychiatrists
 The psychiatry and neuropsychiatry of COVID-19: High incidence of delirium and
psychiatric symptoms including mood, anxiety, and psychotic symptoms; overlap with
neuropsychiatric symptoms is common.
 Up to 85% of critically ill COVID-19 patients have neuropsychiatric manifestations. Systemic
inflammation, hypoxia, direct neurotropic effects of the virus, and iatrogenic effects of
medications (e.g., steroids, sedatives) all contribute to development of symptoms
 Evidence-based guidelines have yet to be established

Shapiro et al, 2021

PROACTIVE MODEL
PROACTIVE MODEL
 Its 4 elements include
 systematic screening for active mental health concerns,
 proactive interventions tailored to individual patients,
 team-based care delivery, and
 care integration with primary teams and services.

 Studies have found that proactive C-L psychiatry is associated with reduced hospital
length of stay, enhanced psychiatric service utilization, reduced time to psychiatric
consultation, and improved provider and nurse satisfaction

Oldham et al, 2021

COLLABORATIVE MODELS
 Approach to integration in which primary care
providers, care managers, and psychiatric consultants
work together
 Both clinically-effective and cost-effective
 Studies have shown that collaborative care interventions
are more effective than usual care for depression,
anxiety disorders, and more serious conditions such as
bipolar disorder and schizophrenia

ACLP source website

COLLABORATIVE MODELS
 INCLUDES
 (1) care coordination and care management;
 (2) regular/proactive monitoring and treatment to target using validated clinical rating scales;
and
 (3) regular, systematic psychiatric caseload reviews
 (4)and consultation for patients who do not show clinical improvement.
 Collaborative care teams include a primary care provider, care management staff, and a
psychiatric consultant
.

ACLP source website

INNOVATIONS USING
TECHNOLOGY
 Availability of digital technology: help strengthen CL services even amidst a pandemic, where
risk of infection was rampant.
 Can help us in systematic screening and early clinical intervention, two of the cardinal
principles of team-based proactive C-L.
 The electronic health record is a powerful tool to improve accuracy and outcomes
 Finn et al demonstrated the feasibility of generating an automated daily report from the
electronic health record that includes diagnoses, orders, and nursing care plans to guide
decisions regarding proactive psychiatric consultation
 Additionally, machine-learning approaches being developed to identify patients with acute
psychiatric needs, understand delirium misdiagnosis in the hospital, predict risk of
developing delirium in patients without known cognitive impairment, and to predict
hospitalization following psychiatric crisis

ACLP source website

TELE CL PSYCHIATRY
 Telepsychiatry in in-patient CL psychiatry is here to stay, especially when isolation and
contagion are factors in patient care.
 Work remains to be carried out to facilitate its use.
 Studies show high patient acceptance for telepsychiatry in outpatient settings; No studies of
efficacy and outcome for CL psychiatry work conducted by phone or video.
 Reduced wait time from 24 hours to 92 mins ( Shayevitz et al, 2020)
 Switching to virtual consultation system early in the pandemic allowed to continue serving
patients while preserving PPE and limiting risk (Caravella et al, 2020)
TELE CL PSYCHIATRY
 Many factors limited the use of remote telepsychiatry with patients, including

 availability of video equipment,

 patient inability or unwillingness to interact through video or telephone,
 availability and willingness of personnel to set up video for the patient, and
 hospital administration hostility to the introduction of remote work.

Shapiro et al, 2021

TEACHING AND TRAINING IN
CL
 Specialised training in CL psychiatry; part of MD training
 Need to adequately train staff, nurses etc at par with the rising demand in CL services
 Courses in CLP offered by RCP, PG diploma courses, DM courses available in INDIA FOR
SUPER SPECIALISATION
 Legal impediment to providing care or advice in a subspecialty for which one is not licensed
to do.
 People, including health-care professionals, often do not recognize just how specialized
psychiatry now is.
RESEARCH
CONCLUSION
 Covid 19 pandemic saw a surge in CL psychiatry cases; paved way for strengthening clp
services.
 Proactive and collaborative care were the sought after models of CL as the psychiatric
morbidity increased and physicians kept a closer watch for the same
 Wider horizons for use of innovations and technology , limited however by logistics and tech
savviness.
 Use of tele psychiatry could go a long way.
 Teaching and training in CL needs to be strengthened from the core
 Opportunities for research to have a clearer quantifiable understanding of impact of changes.