James A. Bourgeois, OD, MD

FROM THE ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY

Academic medical center psychiatry departments, like many other medical specialty areas, often struggle to find contemporary opportunities to grow and consolidate services, maintain market share, and support other clinical divisions. Psychiatry departments traditionally focus on outpatient clinics, hospital-based and emergency-based services, and inpatient psychiatric units as sources of clinical productivity and revenue. Departments with appropriately trained and privileged physicians can supplement clinical revenue with electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), and other neuromodulation interventions.

The development and the recent explosion of opportunities in 

 come at an opportune time. Technologically advanced telepsychiatry functionality, combined with robust electronic health record (EHR) systems, permits high-level clinical service delivery from a secure remote platform. Telepsychiatry has been accepted as an alternative to in-person care by patients and physicians and offers clear benefits in the COVID-19 pandemic environment, facilitates care without a transport burden, and affords physicians a viable opportunity for home-based employment.

Our recent experience with telepsychiatry in an academic department of psychiatry led to significant expansion of clinical services provision and increased administrative efficiency. We are now able to provide robust psychiatric support to emergency departments (EDs), hospital inpatient units, outpatient psychiatric services, and primary care clinics in a complex, geographically dispersed, integrated health system in northern and central Texas (from Dallas to Austin).

Baylor Scott & White Health–Temple Department of Psychiatry

Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. Baylor Scott & White Medical Center–Temple is a comprehensive 636-bed academic medical center and level 1 trauma center and is a main clinical education site for the Texas A&M University College of Medicine Health Science Center. Baylor Scott & White Medical Center–Temple is a 2020 and 2021 Fortune/IBM Watson Health Top 100 Hospital and Top 15 Major Teaching Hospital in the US (No. 2 in 2021). The BSWH system includes 2 academic medical centers, 25 community and specialty hospitals, and 175 primary care clinics, all integrated into a network with a common EHR account.

The Department of Psychiatry at Baylor Scott & White Medical Center–Temple is the only academic psychiatry department in the BSWH system. Personnel include 40 faculty physicians and other clinicians, 20 psychiatry residents, and 6 child and adolescent psychiatry fellows. The Department of Psychiatry is backed by the academic partnership among Texas A&M University Health Science Center, College of Medicine, BSWH, and the Central Texas Veterans Health Care System (CTVHCS). Departmental hospital operations at Baylor Scott & White Medical Center–Temple have included a 23-bed inpatient psychiatry unit with 1275 inpatient discharges per year, more than 2000 annual consultation-liaison encounters, and 24-hour coverage of the emergency psychiatry service.

Departmental outpatient operations include the Alcohol and Drug Dependence Treatment Program, Harker Heights behavioral health clinic, McLane Children’s Hospital behavioral health clinic, embedded psychiatric services in primary care clinics, collaborative care support to BSWH primary care clinics, a comprehensive neuromodulation (ECT, rTMS, ketamine) program, and a BSWH systemwide hospital telepsychiatry consultation service, with more than 42,000 total outpatient encounters per year. The department participates in a strategic partnership between BSWH and a 102-bed freestanding psychiatric inpatient facility. The department is a member of the Neurosciences Institute.

In 2019, we initiated a hospital telepsychiatry service to cover 26 BSWH hospitals that had sparse in-person emergency psychiatric services coverage. This service was previously managed by a third-party telepsychiatry vendor but was excessively costly to the system. There was limited communication between consultants and hospital staff. The services were provided by many telepsychiatry psychiatrists; thus, the ED and hospitalists did not have ongoing collegial relationships with the telepsychiatry group for informal advice such as “curbsiding.”

Mindful of these concerns, we started a 7-physician telepsychiatry service. Seven telepsychiatry faculty positions were developed at the Department of Psychiatry and a faculty member was chosen as service director with a 10% leadership stipend. All telepsychiatry physicians recruited had significant experience in telepsychiatry at other institutions; 1 has a geriatric subspecialty, and 2 have a child and adolescent psychiatry (CAP) subspecialty. A project manager with extensive medical administrative experience was appointed to take charge of this telepsychiatry initiative. All telepsychiatry physicians were credentialed at all facilities served, and all were hired as faculty members in the BSWH Department of Psychiatry. Most coverage shifts have 2 or 3 psychiatrists on duty.

Coverage hours are 8 AM to 10 PM weekdays and 8 AM to 8 PM weekends and holidays. Hospitals were brought on board gradually, with all 26 facilities phased in over a 12-month period. Education of local nursing and administrative staffs was a crucial part of this go-live process. Consultation requests are entered within the EHR. The on-duty administrators organize incoming requests and schedule appointments with the physicians on duty. After examining the patient, the physician charts immediately in the EHR. The consultant communicates with the attending physician in real time by EHR secure messaging and provides input for treating the patient.

This service has had a significant impact on ED length of stay and sitter hours. Each week, various metrics are monitored and feedback is provided to the team. Volume grew steadily and the service has been well accepted by all the facilities served across BSWH.

Beginning in 2020, BSWH made the policy commitment to roll out the collaborative care/TEAMcare model (originated at the University of Washington) to all 175 primary care clinics in the system. Clinic physicians in the Department of Psychiatry devote time weekly in 2-hour increments to interface and support the collaborative care manager and primary care providers (PCPs) in the primary care clinics in their standardized treatment of mild/moderate depressive and anxiety disorders according to protocolized treatment algorithms and regular structured outcomes measures.

Patients whose psychiatric illnesses are too severe/complicated for collaborative care management can be seen for a 1-time telepsychiatry-based consultation by the consulting psychiatrist for diagnostic clarity and treatment planning. Often, the single telepsychiatry consultation by the psychiatrist leads to an enhanced clinical care intervention plan that can then be effectuated by the PCP without ongoing local psychiatric care. More severe or complex patients may be disenrolled from the collaborative care model and referred for local ongoing outpatient psychiatric treatment. Currently, 4 department physicians participate in this model.

In response to the pandemic, in 2020 the department pivoted to 100% telepsychiatry for outpatient psychiatric services within a period of 10 days. With subsequent easing of social distancing requirements, we continued to offer the option of telepsychiatry services. Since that time, a persistent fraction of 30% to 35% of outpatients continue to have their care provided exclusively by telepsychiatry. Since offering telepsychiatry outpatient services have been offered, patient satisfaction has significantly increased and outpatient no-show rates, which had never been less than below 10% despite numerous administrative initiatives, have decreased to near zero.

Inpatient Service Staffing by Telepsychiatry

Our department has recently established a partnership for exclusive physician staffing of a freestanding 102-bed inpatient psychiatry unit, operated by a private company, as our inpatient unit. We were able to bring 2 full-time CAP psychiatrists to take care of the inpatient needs of the 28-bed adolescent unit, exclusively via telepsychiatry. This stabilizes the staffing of this unit, which is also a training site for residents and CAP fellows, liberating the rest of the CAP faculty to serve the clinic and children’s hospital. Overnight and weekend on-call/rounding on inpatient units can also be accomplished by telepsychiatry.

Since the beginning of these initiatives, the department has been able to effectively add 12 physician positions that are exclusively telepsychiatry service based. This creates new employment opportunities for physicians skilled at working in this medium, establishes the department as one with substantial expertise in telepsychiatry, and facilitates hands-on experience in telepsychiatry to psychiatry residents who need to master this skill as part of their clinical repertoire. These additional physicians do not require physical office space at the medical campus and need only minimal administrative support. This enables significant departmental growth (at this point, over 33% of our physicians work exclusively via telepsychiatry) and identifies our psychiatry group as a progressive, modern department.

An additional benefit to promoting telepsychiatry-based clinical services is the indirect but significant impact on physician quality of life and burnout prevention. Robust telepsychiatry opportunities can enable many physicians to continue working from home while taking maternity/paternity leave, recovering from an acute illness or injury, or dealing with a chronic illness (such as immunocompromised states) that makes it unsafe to be in a common public setting like a clinic or hospital. Home-based telepsychiatry physicians can avoid the time and expense of commuting, gaining more free time.

Academic psychiatry departments should embrace the opportunity for telepsychiatry as permitting increased size of the faculty cohort, supporting other medical departments needing psychiatry consultation, and providing enhanced work-life balance for faculty members. Embracing modern technology should be seen as an option-generating opportunity to develop, grow, and optimize department functions.

 is medical director of the Baylor Scott & White Medical Center – Temple Hospital Telepsychiatry Service . 

is director of collaborative care for Baylor Scott & White Health and member of the Baylor Scott & White Medical Center–Temple Department of Psychiatry. 

 is an administrator within the Baylor Scott & White Health Department of Psychiatry and manager of the Hospital Telepsychiatry Service. 

 is chair, Department of Psychiatry, Baylor Scott & White Health Medical Center–Temple, Texas.

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Practical issues in delivery of clinician-to-patient telemental health in an academic medical center

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Telepsychiatry consultation for medical and surgical inpatient units

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Telepsychiatry for inpatient consultations at a separate campus of an academic medical center

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Implementation of a centralized telepsychiatry consult service in a multi-hospital metropolitan health care system: challenges and opportunities

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States leverage telepsychiatry solutions to ease ED crowding, accelerate care

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Telepsychiatry and integrated primary care: setting expectations and creating an effective process for success

12. Hilty DM, Rabinowitz T, McCarron RM, et al. 

An update on telepsychiatry and how it can leverage collaborative, stepped, and integrated services to primary care

COVID-19 and telepsychiatry: early outpatient experiences and implications for the future

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Emerging needs and viability of telepsychiatry during and post COVID-19 era: a literature review

Lessons learned or forgotten? impacts of COVID-19 on the future direction of global (e-)mental health care

16. Kinoshita S, Cortright K, Crawford A, et al. 

Changes in telepsychiatry regulations during the COVID-19 pandemic: 17 countries and regions’ approaches to an evolving healthcare landscape

. 2020;1-8. Published online November 27, 2020.

Telepsychiatry adoption across hospitals in the United States: a cross-sectional study

18. Gardner JS, Plaven BE, Yellowlees P, Shore JH. 

Remote telepsychiatry workforce: a solution to psychiatry’s workforce issues

Articles

How can telehealth help academic psychiatry departments improve administrative efficiency and expand their clinical services?

Telepsychiatry Initiatives in Psychiatry Departments: Enabling Sustainable Growth

Academic medical center departments of psychiatry, like many other medical specialty departments, often struggle to find contemporary opportunities to grow and consolidate clinical services, maintain market share, and support other clinical departments. Psychiatry departments historically focus on outpatient clinics, hospital- and emergency-based services, and inpatient psychiatry units as common sources of clinical productivity and clinical revenue. Departments with the appropriately trained and privileged physicians can supplement clinical revenue with transcranial magnetic stimulation (rTMS), electroconvulsive therapy (ECT), and other neuromodulation interventions.

The development and recent explosion of opportunities in telepsychiatry come at an opportune time. Technologically advanced and secure telepsychiatry functionality, combined with robust EHR systems, permits high-level clinical service delivery from a secure remote platform. Telepsychiatry has proven to be acceptable as an alternative to in-person care by patients and physicians alike, and offers clear benefits in the pandemic environment, facilitates care without a transport burden, and, importantly, affords physicians a viable opportunity for home-based employment.

We discuss our recent experience with telepsychiatry in an academic department of psychiatry that led to significant expansion of clinical services provision and increased clinical administrative efficiency. We are now able to provide robust psychiatric support to emergency departments, hospital inpatient units, outpatient psychiatry services, and primary care clinics in a complex, geographically dispersed integrated health system in north and central Texas (from Dallas to Austin).

Baylor Scott & White Health Department of Psychiatry

Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. Baylor Scott & White Memorial Medical Center in Temple is a comprehensive 636-bed academic medical center and Level 1 trauma center and is a main clinical education site for the Texas A&M University Health Science Center College of Medicine. Baylor Scott & White Memorial Medical Center is a 2020 and 2021 Fortune/IBM Watson Health Top 100 Hospital and Top 15 Major Teaching Hospital in the US (no. 2 in 2021). The BSWH system includes 2 academic medical centers, 25 community and specialty hospitals, and 175 primary care clinics, all integrated into a single network with a common electronic health record (EHR) account.

The department of psychiatry is the only academic psychiatry department in the BSWH system. Personnel include 40 faculty physicians and other clinicians, 20 psychiatry residents, and 6 child and adolescent psychiatry fellows. The department of psychiatry is backed by the academic partnership among Texas A&M University Health Science Center, College of Medicine, BSWH, and the Central Texas Veterans Health Care System (CTVHCS). Departmental hospital operations at Baylor Scott & White Memorial Medical Center have included a 23-bed inpatient psychiatry unit with 1275 inpatient discharges per year, more than 2000 annual consultation-liaison encounters, and 24-hour coverage of the emergency psychiatry service.

Departmental outpatient operations include the Alcohol & Drug Dependence Treatment Program, Harker Heights Behavioral Health Clinic, McLane Children’s Hospital Behavioral Health Clinic, embedded psychiatric services in primary care clinics, collaborative care support to BSWH primary care clinics, a comprehensive neuromodulation (ECT, rTMS, ketamine) program, and a BSWH system-side hospital telepsychiatry consultation service, with more than 42,000 total outpatient encounters per year. The department participates in a strategic partnership between BSWH and a 102-bed freestanding psychiatric inpatient facility. The department is a member of the Neurosciences Institute. 

In 2019, we initiated a hospital telepsychiatry service to cover 26 BSWH hospitals that had had sparse in-person emergency psychiatric services coverage. This service was previously managed by a third-party telepsychiatry vendor, but this service proved to be excessively costly to the system. There was limited communication from consultants with the hospital staff. The services were provided by a large number of available telepsychiatry psychiatrists; thus, the emergency department (ED) and hospitalists did not have ongoing collegial relationships with the telepsychiatry group for informal advice such as “curbsiding.”

Mindful of these concerns, we started a 7-physician telepsychiatry service. Seven telepsychiatry faculty positions were developed at the psychiatry department, and one faculty member was chosen as service director with a 10% leadership stipend. All telepsychiatry physicians recruited had significant experience in telepsychiatry at other institutions; 1 has a geriatric subspecialty, and 2 have a child and adolescent psychiatry (CAP) subspecialty. A project manager with extensive medical administrative experience was appointed to take charge of this telepsychiatry initiative. All telepsychiatry physicians were credentialed at all facilities served, and all were hired as faculty members in the BSWH department of psychiatry. Most coverage shifts have 2 or 3 psychiatrists on duty.

Coverage hours are 8 AM to 10 PM weekdays and 8 AM to 8 PM weekends and holidays. Hospitals were brought on board gradually with 1 or 2 phased in every few weeks. All 26 facilities were phased in over a 12-month period. Education of local nursing and administrative staffs was a crucial part of this go-live process. Consultation requests are entered within the EHR. The on-duty administrators organize the incoming requests and schedule the appointments with the physicians on duty. After examining the patient, the physician charts immediately in the EHR. The consultant communicates with the attending physician in real time by EHR secure messaging and provides input for managing the patient.

This service has had a significant impact on ED length of stay (LOS) and sitter hours. Various metrics are monitored on a weekly basis, and feedback is provided to the team during weekly huddles. The volumes grew steadily, and the service has been well accepted by all the facilities served across BSWH.

Beginning in 2020, BSWH made the policy commitment to roll out the collaborative care/TEAM care model (originated at the University of Washington) to all 175 primary care clinics in the system. Clinic physicians in the department of psychiatry devote time weekly in 2-hour increments to interface and support the collaborative care manager and primary care providers (PCPs) in the primary care clinics in their standardized treatment of mild/moderate depressive and anxiety disorders according to protocolized treatment algorithms and regular structured outcomes measures.

In response to the COVID-19 pandemic, in 2020 the department pivoted to 100% telepsychiatry for outpatient psychiatric services in a period of 10 days. With subsequent easing of social distancing requirements, we continued to offer the option of telepsychiatry services. Since that time, a persistent fraction of 30% to 35% of outpatients continue to have their care provided exclusively by telepsychiatry. Since offering telepsychiatry outpatient services, patient satisfaction has significantly increased and outpatient no-show rates, which had never been less than 10% despite numerous administrative initiatives, have now decreased to near zero.

Since the beginning of these initiatives, the department has been able to effectively add 12 new physician positions, which are exclusively telepsychiatry service-based. This creates new employment opportunities for physicians skilled at working in this medium, establishes the department as one with substantial expertise in telepsychiatry, and facilitates hands-on experience in telepsychiatry to psychiatry residents who need to master this skill as part of their clinical repertoire. These additional physicians 

 require physical office space at the medical campus and need only minimal administrative support. This enables significant departmental growth (at this point, over 33% of our physicians work exclusively via telepsychiatry) and identifies our psychiatry group as a progressive, modern department.

An additional benefit to promoting telepsychiatry-based clinical services is the indirect, but significant impact on physician quality of life and preemptive burnout prevention. Robust telepsychiatry opportunities can facilitate many physicians to continue working from home while on maternity/paternity leave, recovering from an acute illness or injury, or while dealing with a chronic illness (such as immunocompromised states) that makes it unsafe to be in a common public setting such as a clinic or hospital. Home-based telepsychiatry physicians can avoid the time and expense of commuting and thus have more free time.

Academic psychiatry departments should embrace the opportunity for telepsychiatry as permitting increased size of the faculty cohort, support of other medical departments needing psychiatry consultation, and providing enhanced work-life balance for faculty members. Embracing modern technology should be seen as an option-generating opportunity to develop, grow, and optimize department functions.

 is medical director of behavioral health at Baylor Health Care System. 

 is a psychiatrist in Temple, Texas, who is affiliated with Baylor Scott & White Health. 

is an administrator within the Baylor Scott & White Health Department of Psychiatry. 

is chair, Department of Psychiatry, Baylor Scott & White Health, Central Texas Division, and clinical professor of medical education, College of Medicine, Texas A&M University Health Science Center, Temple, Texas.

 [published online ahead of print, 2021 Nov 15]. 

Changes in telepsychiatry regulations during the COVID-19 pandemic: 17 countries and regions' approaches to an evolving healthcare landscape

 [published online ahead of print, 2020 Nov 27]. 

Remote telepsychiatry workforce: a solution to psychiatry's workforce issues

Doctors share their experiences with telepsychiatry in an academic department of psychiatry that led to significant expansion of clinical services and greater administrative efficiency.

Telepsychiatry Initiatives at an Academic Medical Center Department of Psychiatry: Enabling Sustainable Growth

The goal of this activity is to help psychiatrists recognize and treat autoimmune encephalitis, despite the fact that it will often initially present as psychosis.

After participating in this activity, you should be better prepared to:

1. Describe the prognostic factors for anti-NMDA [N-methyl-D-aspartate] receptor encephalitis (ANMDARE).

2. Conduct a clinical workup and treatment plan for recurrent ANMDARE episodes.

This accredited continuing education (CE) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

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In recent years, a growing body of literature has described autoimmune encephalitis as an important, if infrequently seen, cause of subacute onset of psychotic illness in patients. One of the important syndromes in this group is anti-NMDA (N-methyl-D-aspartate) receptor encephalitis (ANMDARE).

 may experience exclusively psychiatric symptoms (eg, psychosis, depressive symptoms), they will likely initially present to psychiatrists. The psychiatrist therefore must consider various components of the presentation in clinical evaluation and management.

Psychotic and depressive illnesses are common in the population, compared with ANMDARE. Consequently, psychiatrists must decide which patients warrant consideration of ANMDARE and the associated diagnostic studies, which are quite detailed and not part of a typical workup for psychotic and depressive disorders. Three broad areas can guide the physician: atypicality of presentation, comorbid neurologic symptoms and signs, and other systemic medical comorbidity commonly reported in ANMDARE. Ultimately, clinical intervention, treatment approaches, and surveillance for recurrence and prognosis will need to be considered.

Atypicality of presentation is an inherently imprecise construct, in that it refers to how a given case presents differently from other more common presentations of the same illness. Herein lies the conceptual challenge. Understanding the construct of 

 requires the clinician to apply an initial classification template to the overall gestalt of a case. For psychotic illness, the physician starts with an observation of the primacy of disordered reality testing (eg, delusions, hallucinations) and thought process (eg, looseness of associations, thought blocking, disorganization) in patient presentation. The primacy of the psychotic symptoms must outweigh other psychiatric findings (eg, depressive, anxiety, cognitive symptoms) so as to define the case as 

Once psychiatrists apply the general template, they may notice that the details of the case do not quite fit. Hence, 

. Atypicality may include epidemiologic features (eg, psychotic symptoms occurring at a later-than-typical age of onset; psychotic illness in a patient with no similar family history), course of presentation (eg, a patient with abrupt onset of psychosis that develops rapidly to impair function without a prodromal state), and social context (eg, onset of psychotic illness without notable social stressors temporally associated with illness onset).

Comorbid neurologic symptoms and signs should be routinely considered in any 

; after all, psychiatric illnesses are, by definition, brain diseases. Specific consideration of motor signs, sensory symptoms, seizures, and disorders of arousal and attention should be considered. The more coincident neurologic comorbidities that are present, the greater the likelihood of ANMDARE and other neuropsychiatric illnesses will be as a central explanatory hypothesis.

Finally, it is important to consider comorbid systemic (ie, non-central nervous system) illness. Psychotic illness occurring in the presence of rheumatologic illness with the use of immunomodulators, endocrinologic illness (eg, hypothyroidism), and/or with concurrent neoplasms raises the odds that the psychotic presentation may be directly attributable to systemic factors being etiologically associated with an illness with an apparent primary psychotic psychiatric presentation.

To make an ANMDARE diagnosis, it is important to consult with a neurologist to obtain a lumbar puncture for cerebrospinal fluid (CSF) studies, magnetic resonance imaging (MRI) (unless the psychiatrist has already obtained it), and 

 (EEG). Once the diagnosis is rendered, clinical intervention needs to be coordinated with other physicians. Clinicians should use antipsychotic and antidepressant medication to address manifest symptoms, but there is a likelihood that systemic immunomodulation therapies (eg, corticosteroids, intravenous immunoglobulin [IVIG], plasma exchange) may ameliorate the psychotic symptoms, such that long-term maintenance with antipsychotic or antidepressant medication may not be indicated. Similarly, resection of an ovarian teratoma may lead to improvement in symptoms.

The prognosis for recurrence of atypical psychiatric illness due to ANMDARE is likely different from recurrence in more common psychiatric illness. In known ANMDARE, vigilance for recurrence should be permanent and lifelong. Recurrence of any clinically significant psychiatric illness should prompt reevaluation of neurologic and systemic medical status via a coordinated effort by the various physician specialties, while empirically treating the presenting symptoms. This is analogous to a patient with a known history of 

 disease, wherein a recurrence of psychiatric symptoms mandates a prompt reevaluation of thyroid status and consideration of a change in endocrinologic treatment in addition to empiric use of psychotropic medications.

The growing literature on recurrence and prognosis in ANMDARE can guide the psychiatrist in management of these patients over time (

Pollak and colleagues presented an integrated approach to the identification of possible, probable, and definite 

 and outlined the options for their appropriate diagnosis and management.

 Psychiatric symptoms consistent with possible autoimmune encephalitis include abrupt onset of psychosis (with rapid progression within 3 months); movement disorder (eg, catatonia, dyskinesia); adverse response to antipsychotics, raising suspicion of neuroleptic malignant syndrome; disproportionate cognitive dysfunction; as well as decreased level of consciousness.

A diagnosis of probable or definite autoimmune encephalitis would further require confirmatory CSF, MRI, and/or EEG studies. Comorbid, nonpsychiatric red flags (eg, infectious prodrome, severe headache, focal neurologic signs, dysautonomia, tumor, hyponatremia, and other autoimmune disorders) should arouse suspicion of 

 The preferred treatment of psychosis in the acute phase is with second-generation antipsychotics, starting at low doses and titrating slowly. Benzodiazepines are indicated in the management of catatonia and in unclear cases of psychosis or aggression. Electroconvulsive therapy (ECT) has shown to be helpful in some cases for rapid symptom control.

If neuronal autoantibody seropositivity is the only abnormality, treatment with immunotherapy may be dangerous and is therefore not recommended. Treatment should be considered on a case-by-case basis following evaluation by a team of neurologists and psychiatrists. Circulating antibodies should be removed via tumor removal, plasma exchange, immunoadsorption, or IVIGs, followed by immunosuppression (with either steroids or steroid-sparing immunomodulating agents such as azathioprine, methotrexate, or mycophenolate mofetil).

Utilizing a study of 382 patients with ANMDARE, Balu and colleagues constructed a grading score for predicting a patient’s neurologic function 

 The study results indicated that intensive care unit (ICU) admission, treatment delay > 4 weeks, lack of clinical improvement within 4 weeks, abnormal brain MRI suggestive of encephalitis, and CSF white blood cell count >20cells/µL were independent predictors for outcome. Poor functional status was defined as a modified Rankin Scale (mRS) score ≥ 3, and good functional status was defined as mRS score ≤ 2. Each of the 5 variables were equally weighted at 1 point each to construct a 5-point anti-NMDAR Encephalitis One-Year Functional Status (NEOS) score. The NEOS score was strongly associated with the probability of poor functional status at 1 year (

). These findings suggest that the NEOS score accurately predicts 1-year functional status and should be used to estimate the velocity of clinical improvement, not the ultimate clinical outcome.

Table 2. NEOS Score and Functional Status at 1 Year

A retrospective case-control study looked at the 

sensitivity and specificity of serum and CSF antibody testing in patients with ANMDARE

 as well as the correlation among titers, relapses, and eventual outcome.

 The study included 250 patients with ANMDARE and 100 control participants. All 250 patients had NMDAR antibodies in CSF, but only 86% of patients had antibodies in the serum. CSF and serum titers were higher in patients with poor outcome as well as in those with teratoma. Over time, there was a decrease of antibody titers regardless of outcome. Relapse correlated better with titer change in CSF than that in serum. The findings suggest that NMDAR antibody testing is more sensitive using CSF than using serum. Antibody titers in CSF and serum are higher in patients with poor outcome or teratoma.

Huang et al conducted a literature review examining the 

prognostic factors and treatment of ANMDARE

 They found that the proportion of patients with deficits during long-term follow-up ranged from 27% to 85% and the recurrence rate ranged from 12% to 29%, with a median interval of 2 years. Most patients responded well to first-line treatment and tumor removal. When first-line immunotherapy fails, second-line immunotherapy can improve outcome. Immunomodulators and tumor removal are effective for pregnant patients. Benzodiazepines are preferred for patients with catatonia, and ECT may be used when pharmacological treatment fails.

Further, Huang and colleagues found that older age and ICU admission were poor prognostic factors. They also found that antibody titers may not be early or sensitive biomarkers, as most patients will still have anti-NMDAR antibodies in the CSF and serum for months to years after treatment. Instead, early prognostic biomarkers included cell-free mitochondrial DNA, interleukin-17, YKL-40 (chitinase 3-like 1), neuron-specific enolase, and S100 calcium-binding protein B; the presence of any of these means a poor response to immunotherapy is more likely. The literature also indicated that those who did not receive adequate immunotherapy to treat the first episode were more likely to relapse. First-line immunotherapy treatments include IVIG, plasma exchange, and high-dose corticosteroids. Second-line treatments should include rituximab and cyclophosphamide. Third-line therapy includes tocilizumab, methotrexate, bortezomib, azathioprine, and mycophenolate mofetil, many of which have not been systemically verified in large cohorts.

 of 571 patients with ANMDARE found that that 23 patients (4%) developed isolated psychiatric episodes: 5 at disease onset and 18 during relapses (

 Brain MRI was abnormal in 45% of these patients, and CSF showed pleocytosis in 77%. Furthermore, 83% had substantial recovery after immunotherapy and tumor resection when appropriate. After relapse, 94% of patients improved or returned to a similar or better prerelapse functional level. These findings suggest that isolated psychiatric episodes are rare, but they can occur as initial onset or relapse of ANMDARE. Patients with new-onset psychosis, history of encephalitis, subtle neurological symptoms, and/or abnormal ancillary tests should be screened for NMDAR antibodies.

Figure. Psychiatric Episodes in Patients With ANMDARE

retrospective cohort study that included 60 patients with ANMDARE

, results showed that age ≥ 25 years, disturbance of consciousness at admission (defined as Glasgow Coma Scale < 5), and ≥ 50% slow waves (4-8 Hz theta waves or 0.5-4 Hz delta waves) on EEG were significantly associated with poor patient outcome.

 These 3 factors make up the 5-point age, consciousness, and slow waves (ACS) composite score, which are scored with 1, 1, and 2 points, respectively. An ACS > / = 3 meant a poor prognosis, defined as mRS score ≥ 3, whereas an ACS < 3 meant a good prognosis, defined as mRS score ≤ 2. The ACS score was determined to have a sensitivity of 84% and specificity of 74%. The study found 38% of patients had good prognoses. These results suggest that the ACS score may be used to predict the early-stage prognosis of patients with ANMDARE.

Titulaer and colleagues conducted a retrospective study of 501 patients with ANMDARE; 81% of which were female, 38% had an underlying neoplasm, and 97% of those with a neoplasm were female.

 Of note, 65% of adults presented with behavioral problems, and 50% of children younger than 12 years presented with seizures or movement disorders. Regarding intervention, 94% underwent first-line immunotherapy or tumor removal, resulting in improvement within 4 weeks in 53% of those patients. For the remaining participants who failed first-line therapy, 57% received second-line immunotherapy, which led to better outcomes than in those who did not receive second-line immunotherapy. During the first 24 months, 79% achieved a good outcome while 6% died. At the 24-month follow-up, 81% had a good outcome, and 9.5% had died. Outcomes continued to improve for up to 18 months after symptom onset.

Early treatment and lack of ICU admission predicted good outcome

 During the 24-month follow up, 45 patients had relapses; for 15 patients, multiple relapses occurred. Relapses were milder than previous episodes in 67% of the cases, monosymptomatic in 35%, and resulted in fewer admissions to the ICU in 17% of the cases. In cases with relapses, the severity of symptoms was comparable with that of the initial episode in 23% of the cases and worse in 10%. The use of immunotherapy in the initial episode of encephalitis was associated with a lower frequency of relapses. A relapse-decreasing effect of second-line immunotherapy was observed in patients without tumor. The introduction of second-line immunotherapy during relapses decreased the frequency of subsequent relapses. The findings suggest that second-line immunotherapy is usually effective when first-line therapies fail. Recovery can take more than 18 months.

relationship between EEG results and ANMDARE recognition

, van Sonderen et al conducted a retrospective cohort study of 35 adults and 18 children with ANMDARE.

 Control EEGs were added to the data set for blinding. The median time from disease onset to the first EEG recording was 19 days for adults and 8 days for children. The results showed that in the majority of patients (71%), first EEGs showed normal posterior rhythm, which was associated with a shorter hospital stay and better clinical outcome, measured by the mRS at follow-up at least 6 months after disease onset. EEGs commonly showed focal (73%) or diffuse slowing (67%). First EEGs containing severely abnormal readings (ie, lack of normal posterior rhythm with severe slowing, periodic discharges, or status epilepticus) were associated with a longer hospital stay. However, 57% of patients who had severely abnormal EEGs still had a good clinical outcome. Extreme delta brushes (EDBs) were present in only severely affected patients with mRS score ≥ 4. An abnormal EEG result has a 96% sensitivity for ANMDARE, but a normal EEG did not exclude the disease. The findings suggest that the first EEGs commonly show normal posterior rhythm, which is associated with a better clinical outcome at least 6 months after disease onset. Additionally, diffuse and focal slowing are common EEG findings; EDBs are present only in severely affected patients; and abnormal EEGs can still result in good clinical outcome.

In regard to EEGs, a literature review found that patients with a normal EEG background, epileptic discharge, polymorphic delta rhythm, and diffuse β activity have a good long-term prognosis, but abnormal EEG readings (eg, EDB) have 

no clear correlation with the final clinical outcome

 Imaging findings show poor specificity and have limited prognostic value. Fluorodeoxyglucose-positron emission tomography (FDG-PET) has a high sensitivity for the most severe forms of ANMDARE. Although antibody titers increase at the onset of the disease, the improvement of symptoms after treatment was not found to be associated with a decline in antibody titers. Like the findings noted in 

 the titers remained positive for a while even after recovery. The relationship among CSF antibody titer, prognosis, and relapse still requires further research. Treatment includes early initiation of immunotherapy and tumor removal, both of which expedite recovery and decrease ANMDARE recurrence risk. Wang et al found that those who required ICU support had a poorer prognosis.

Warren and colleagues conducted a retrospective cohort study to better understand the 

 The study included 30 patients who tested CSF positive for ANMDARE; results showed that a majority of patients (83%) had early psychiatric symptoms, including agitation and psychosis within the first week of admission and 3 cases of catatonia within the second week. These patients were treated with antipsychotics (67%), with an average daily olanzapine equivalence dose of 11.5 mg, prior to immunomodulation therapy. Although there was an 88% reduction in cases with aggression, antipsychotics alone provided little improvement in psychosis, affective symptoms, or catatonia.

Warren et al found no significant difference in the rate of occurrence of neurological and autonomic symptoms (ie, extrapyramidal symptoms [EPS] and neuroleptic malignant syndrome [NMS]) between those who received antipsychotics (20 patients) vs those who did not receive them (5 patients). Four patients experienced a possible recurrence of encephalitis: 1 who had seizures and 3 others with cognitive deterioration, mild movement disturbance, and recurrence of psychosis despite being continued on antipsychotic medications. All 4 cases resolved with immunomodulation therapy.

These findings suggest a need for psychiatric care for those with ANMDARE in both acute and chronic phases. Antipsychotic medications should be considered an adjunct to immunomodulation therapy. Suspected NMS and EPS cannot be differentiated easily from clinical progression of ANMDARE. Clinical reevaluation, careful withdrawal of potential causative agent, and immunomodulation therapy should be considered. Psychiatric management and psychotropic medication choice must be flexible, with dosing modifications depending on the most pressing psychiatric symptom, stage of illness, neurological symptoms, and risks of adverse effects.

 studied the CD138 levels as well as many other biomarkers in the serum and CSF of patients with ANMDARE.

 CD138 is a component of the endothelial cell glycocalyx. The study included 27 patients with ANMDARE, 11 with viral meningoencephalitis, and 22 control participants, and the results showed that serum and CSF levels of CD138 were significantly increased in patients with ANMDARE. After 3 to 6 months, their CSF CD138 levels were significantly decreased. Decreases in CD138 levels were associated with an improvement in the clinical outcome measured by the mRS. The findings suggest that a high level of CSF CD138 is associated with inflammation and poor prognosis.

In a recent major review of autoimmune encephalitis (comprising multiple mechanisms, including ANMDARE), 

 reviewed 44 publications representing 2823 reported patients, of which 27 studies and 1566 cases were ANMDARE.

 Specifically pertaining to prognosis for ANMDARE, and mindful of the emerging and somewhat varied research methodology in this area, the authors concluded that ANMDARE prognosis was worse with delay in initiation of or lack of immunotherapy, altered level of consciousness at clinical presentation, and admission to ICU. Other clinical variables, such as older age, sex, status epilepticus at clinical presentation, and abnormal CSF and MRI studies, did not have significant prognostic value, while the impact of antibody titers, dysautonomia, and comorbid malignancy was uncertain.

The literature illuminates some key points about clinical presentation, risk factors, prognostic factors, clinical workup, and treatment recommendations for recurrent ANMDARE. Although ANMDARE usually presents initially as an abrupt onset of psychosis with comorbid neurologic symptoms and/or systemic symptoms, recurrent episodes may present, in rare cases, as an isolated change in mood or behavior (eg, delusional thinking, mood disturbances, aggression).

Risk factors for ANMDARE recurrence include 

 in the treatment of the initial encephalitis episode,

 Poor prognostic factors include later initiation of treatment (more than 4 weeks after initial onset of symptoms) and ICU admission.

Many possible prognostic biomarkers are still under study, but some are at least partially understood. A normal EEG background, epileptic discharge, polymorphic delta rhythm, and diffuse beta activity are associated with a shorter hospital stay and good long-term prognosis, but abnormal EEG readings (eg, EDBs) have no clear correlation with the final clinical outcome.

 The ACS (age, disturbance of consciousness, and slow waves on EEG) score may be valuable in predicting the 

 The NEOS score may be used to predict the functional status after 1 year,

 Patients experiencing recurrent episodes should undergo proper clinical workup to minimize the risk of further recurrence and improve prognosis.

For recurrent cases of ANMDARE, a detailed workup should be completed (

 If the serum or CSF is positive for any onconeural antibodies, consider a 

Table 3. A Workup for Suspected Recurrent ANMDARE

Antibody titers should be interpreted with caution, as they may not be early or sensitive biomarkers. The improvement of symptoms has not been found to be associated with a decline in antibody titers.

 Therefore, treatment decisions should be based more on 

 For those who present with atypical clinical findings, such as the presence of a characteristic syndrome with negative serum antibodies or a discrepancy between serum and CSF antibodies, obtain 

 (serum and CSF using 2 different techniques [eg, cell-based assay, brain immunohistochemistry, IIFT, ELISA, RIA, nanoliter immunoassay]).

 between neurologists and psychiatrists is necessary to manage co-occurring neuropsychiatric symptoms.

 If the patient presents with rapidly progressive, refractory psychosis, and cognitive decline, consider

Treatment of first-episode and recurrent ANMDARE cases are similar. Both involve removal of circulating antibodies via tumor removal as well as plasma exchange, immunoadsorption, IVIGs, and/or immunosuppressors (eg, corticosteroids, azathioprine, methotrexate, mycophenolate mofetil).

 For unconfirmed cases of ANMDARE (eg, serum-only NMDAR antibody positivity without any other clinical abnormality), treatment with immunotherapy is not recommended and should be reviewed on a case-by-case basis by a team of neurologists and psychiatrists.

 For those who do not respond to first-line therapy with IVIG, plasma exchange, or high-dose corticosteroids, second-line immunotherapy with rituximab, cyclophosphamide, or both can 

significantly improve the outcome and decrease the frequency of relapses

In addition to immunomodulation, psychotic symptoms should be specifically managed. For the treatment of agitation, avoid high-potency antipsychotics (eg, haloperidol, risperidone) as they can worsen motor symptoms.

low-dopamine receptor blocking second-generation antipsychotics

, starting at low doses and up-titrating slowly.

 Highly sedating medications such as quetiapine, chlorpromazine, valproic acid, and benzodiazepines have anecdotally been useful for psychiatric symptoms,

 for catatonia and unclear cases of psychosis or aggression.

 ECT can be helpful for immediate symptom control.

 After the patient’s recovery from the ANMDARE episode, obtain their baseline serum and CSF titers to monitor for possible relapses; of the 2, the CSF titer is a more reliable indicator of new-onset relapse. Nevertheless, clinicians should base their treatment decisions more on clinical evaluation, rather than antibody titers, as the relationship among CSF antibody titer, prognosis, and relapse is still being studied.

Monitoring for recurrence is lifelong, as ANMDARE episodes can reoccur months to years after initial onset. Further randomized controlled trials are needed for a universal consensus on management of ANMDARE.

is a recent graduate of Texas A&M College of Medicine and has recently joined the Texas A&M Psychiatry Residency Program in Bryan, Texas. 

1. Pollak TA, Lennox BR, Müller S, et al. 

Autoimmune psychosis: an international consensus on an approach to the diagnosis and management of psychosis of suspected autoimmune origin

Anti-N-methyl-D-aspartate receptor encephalitis: a review of pathogenic mechanisms, treatment, prognosis

3. Kayser MS, Titulaer MJ, Gresa-Arribas N, Dalmau J. 

Frequency and characteristics of isolated psychiatric episodes in anti-N-methyl-d-aspartate receptor encephalitis

This CME covers how CNS-related psychosis may require medical interventions beyond antipsychotic and other psychotropic medications.

James A. Bourgeois, OD, MD

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