Zimbrean, Paula C.

Background Catatonia in medically ill patients is rare but often unrecognized. This monograph summarizes current knowledge on the diagnosis, epidemiology, etiology, and management of catatonia occurring in the medical setting. Methods PubMed searches were used to identify relevant articles from 1962 to present. Results More than 3,000 articles were obtained and reviewed for relevance, including references of articles identified by the initial search. Several areas were identified as important, including: (1) catatonia and delirium; (2) malignant catatonia; (3) pediatric catatonia; (4) catatonia associated with another medical condition (CAMC); (5) drug exposure and withdrawal syndromes associated with catatonia; and (6) treatment of catatonia in the medical setting. Conclusions Catatonia in the medically ill appears to have numerous etiologies, although etiology does not seem to modify the general treatment approach of prompt administration of lorazepam. Delirium and catatonia are commonly comorbid in the medical setting and should not be viewed as mutually exclusive. Electroconvulsive therapy should be offered to patients who do not respond to benzodiazepines or have malignant features. Removing offending agents and treating the underlying medical condition is paramount when treating CAMC. Memantine or amantadine may be helpful adjunctive agents. There is not enough evidence to support the use of antipsychotics or stimulants in treating CAMC.

Hazardous alcohol use remains a major contributor to acute and chronic liver disease, while alcohol-associated liver disease (ALD) is a leading indication for liver transplantation. In recent years, embedded, interprofessional ALD clinics have improved access to alcohol use disorder care within hepatology and liver transplantation, but more work is needed to meet this challenge. The literature is lacking regarding scaling procedures to provide services for increasingly large ill patient populations. This article begins to fill this gap by describing “expanded ALD care”: broad, innovative, longitudinal, interprofessional care delivery strategies surpassing standalone clinics. Drawing from analogous patient populations served by collaborative models in primary care and comprehensive eating disorder treatment, the expanded ALD care framework proposes practical strategies toward specific innovations: equipoise between biomedical and psychosocial care elements, increased clinician number and reach, long-term patient relationships, harm reduction and palliative care, outreach to external agencies and clinicians, and enhanced support for patients and families. The article also defines attributes of innovative healthcare systems that support expanded ALD care.

Background. Liver transplantation (LT) is the standard treatment for liver failure secondary to alcohol-associated liver disease, but limited literature and best practices exist for post-LT treatment of alcohol use disorder (AUD). This study explores current AUD management practices and providers’ perceived barriers to effective post-LT AUD management. Methods. A 45-item survey on post-LT AUD treatment practices was distributed to members of the American Society of Transplant Surgeons, the Association of Consult/Liaison Psychiatry Transplant Special Interest Group, and both the American Society of Transplantation’s Liver and Intestine Community of Practice and Psychosocial and Ethics Community of Practice discussion boards, between December 2021 and April 2022. Univariate analysis of categorical variables was performed using the chi-square test. Data were analyzed using center volume tertiles, country region, and provider professional activity. Results. Two hundred thirty-two respondents from 70 LT centers across all 11 United Network for Organ Sharing regions completed the survey. Half of the them were attending physicians and 16.4% were nurse coordinators. Most centers (84%) aimed for alcohol abstinence for all post-LT patients. Perceived barriers to AUD treatment efficacy included ongoing desire to drink (18%), denial about alcohol misuse (14.9%), and lack of posttransplant support (14%). Additionally, 62.1% of centers had no policy for prescribing medication-assisted therapy to treat AUD, and 32.7% of centers reported no center-level changes in AUD care. Providers identified primary needs as hiring additional mental health professionals (30.8%), dedicating specific staff to AUD care (24.7%), and standardizing psychiatric/psychological care in transplant clinics (17.2%). Conclusions. Despite the increasing volume of LT for alcohol-associated liver disease, significant perceived barriers to effective AUD treatment remain.