[Fred A. Baughman Jr., MD:
http://www.medscape.com/viewarticle/462577 Cornell Psychiatric Screen Validated: A Newsmaker Interview With Stephen J. Ferrando, MD Laurie Barclay, MD Oct. 7, 2003 - Editor's Note: The Cornell Psychiatric Screen suggests that many medical inpatients [Fred A. Baughman Jr., MD:
would benefit from psychiatric services, according to the results of a preliminary validation study published in the September-October issue of Psychosomatics. This brief, reliable, and valid [Fred A. Baughman Jr., MD:
screening tool includes items assessing cognition and behavior, depressive symptoms, anxiety, drug and alcohol history, and the patient's desire to see a psychiatrist. Among patients in whom the screen suggested possible psychopathology [Fred A. Baughman Jr., MD:
, 89% had documented psychiatric comorbidity according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. To learn more about how this screen should be used, Medscape's Laurie Barclay interviewed Stephen J. Ferrando, MD, an associate professor of psychiatry at the Weill Medical College of Cornell University in New York City and the director of the psychiatric consultation liaison service at New York-Presbyterian Hospital. Medscape: Why is a psychiatric screen needed for hospitalized medical patients? Dr. Ferrando: The prevalence of psychiatric comorbidity is very high in medical inpatients, up to 40% to 50% in some studies [Fred A. Baughman Jr., MD:
. Despite that, the rate of psychiatric consultation is very low, usually less than 5%. [Fred A. Baughman Jr., MD:
Identifying psychiatric disease in this population is important because psychopathology increases length of stay and medical morbidity and results in poor functional outcomes. The idea of the screen is to identify these patients and to intervene early to improve outcomes [Fred A. Baughman Jr., MD:
. Medscape: What were the main findings of this study? Dr. Ferrando: The study's intent was to develop this screening instrument, which we did, as well as to validate it. We started with a large number of questions, then honed it down to seven items, five of which are self-reported, and the other two are rated by a paraprofessional, nurse, or an attendant who is trained to ask simple but directed questions. This screen gives the patient a mental health severity rating and only takes about five minutes to administer. We looked at the predictive value of the instrument and developed cutoff criteria. When the score met the criteria, the screen was accurate 90% of the time in predicting psychiatric disease. The absolute score also correlated with the length of stay. Now we're using this screening instrument in a randomized trial of early psychiatric intervention versus standard care, with 200 medically ill patients in each group. The results are in preparation. Medscape: Could psychiatric symptoms associated with medical illness, such as fatigue associated with cancer or hallucinations accompanying metabolic delirium, confound the results of this screen? Dr. Ferrando: Not really. Any of these symptoms can be associated with overall medical morbidity, but the psychiatrists still have to deal with it. With the symptom of fatigue in a cancer patient, for example, the primary medical team is pushing chemotherapy while the psychiatrist should be addressing quality-of-life issues, perhaps prescribing a stimulant like Provigil or suggesting other ways to cope with the fatigue. So even though the psychiatric symptoms may have a medical basis, the psychiatrist can still be helpful. Medscape: Does the screen help distinguish patients with psychopathology who are not in need of acute psychiatric intervention from those who could benefit from psychiatric consultation while hospitalized for other conditions? Dr. Ferrando: It's possible that the screen could detect patients with psychopathology mild enough not to require intervention. We tried to minimize that by setting the cutoff to reflect greater severity. To get counted toward the total score, for example, symptoms had to be present most or all of the time. Medscape: Should all hospitalized medical patients be screened, or are there certain criteria that identify groups at high risk? Dr. Ferrando: For this study, we chose patients in the moderate range of medical severity, because the impact of psychiatric comorbidity is probably greatest in these patients in the middle of the spectrum. Patients with less severe medical problems are in and out of the hospital too quickly for psychiatric intervention, and those with very severe problems have more pressing medical issues that must be addressed first. Medscape: What are the limitations of this screen in detecting mental illness? Dr. Ferrando: Our study was not designed to test the false-negative rate of the screen, because we didn't do a psychiatric evaluation on every patient, but only on those in whom the screen was positive. That's a very important limitation of our study. It is certainly possible that subtle manifestations of mental illness could be missed. Medscape: Are there any potential negative consequences of this screen, such as having a fragile but compensated individual decompensate under the stress of discussing psychiatric disease, creating concern in a patient that the doctor thinks their medical illness is "all in their head," or otherwise alienating the staff from the patient? Dr. Ferrando: It's theoretically possible, but we just didn't find that at all. The literature also suggests that screening instruments tend to decrease rather than increase patient stress. We've tested the screen in more than 400 patients, and it is generally very well accepted when we present it as a part of their overall comprehensive, holistic care. New York-Presbyterian Hospital funded this study. Dr. Ferrando has received honoraria from Pfizer, Merck, Sharp & Dohme, and Bristol-Myers Squibb. Psychosomatics. 2003:44:382-387 Reviewed by Gary D. Vogin, MD ---------------------------------------------------------------------- Laurie Barclay, MD Writer for Medscape Medical News Medscape Medical News is edited by Deborah Flapan, assistant managing editor of news at Medscape. Send press releases and comments to news@webmd.net. |
Leave a Reply