The Impact of Embedded Psychiatry in Neurological Care (Podcast)

For patients with neurological disorders, getting the right mental health treatment often warrants another referral, another appointment and another wait. By embedding neuropsychiatrists in its neurological clinics, Cleveland Clinic is aiming to address those challenges by strengthening collaboration among specialists.

Neuropsychiatrist Drew Cumming, MD, says the model builds on the longstanding practice of consultation-liaison psychiatry while bringing that expertise directly into the outpatient setting.

“Embedding a psychiatrist within a specialty clinic just makes sense,” Dr. Cumming says. “It can reduce wait times for mental healthcare and allows psychiatrists to develop specialized knowledge of the patient populations they serve. Through repeated exposure, neuropsychiatrists become familiar with what is typical for a particular neurological condition, what is less common but possible, and when a patient’s symptoms warrant further investigation."

In the latest episode of Cleveland Clinic’s Neuro Pathways podcast, Dr. Cumming discusses the benefits of close collaboration between neurologists and psychiatrists, the prevalence of psychiatric symptoms in patients with neurological disorders, the critical role of psychologists and social workers, and patient perceptions and stigma surrounding mental health care. He also describes the challenges of treating Parkinson’s dementia and distinguishing between medication-related and disease-related symptoms.

Click the podcast player above to listen to the 30-minute episode now or read on for an edited excerpt of its transcript. Check out more Neuro Pathways episodes at clevelandclinic.org/neuropodcast or wherever you get your podcasts.

This activity has been approved for AMA PRA Category 1 Credit™ and ANCC contact hours. After listening to the podcast, you can claim your credit here.

Podcast excerpt

Podcast host Glen Stevens, DO, PhD: Can you tell us a little bit about some of the neuropsychiatric issues associated with Parkinson’s disease?

Dr. Cumming: Well, we certainly see increased rates of depression and anxiety with Parkinson's. As many as 60% of these patients are going to experience a certain degree of psychosis. It's a peculiar beast – and from my perspective, very interesting. Parkinson’s psychosis and significant apathy are probably the two most significant neuropsychiatric challenges these patients face.

Patients taking extra dopaminergic medications can start to hallucinate. In addition, as the disease progresses, there are changes that affect serotonin receptor density in the cortex and influence glutamate transmission and theventral tegmental area. This can trigger…a centrally mediated psychotic process.

The first time [psychosis] happens in a patient with Parkinson's, it’s most likely a side effect of medication, especially if symptoms start in the days or weeks after a medication change. If it happens later in the disease course and there hasn't been a change in the patient’s medications or deep brain stimulation settings, the symptoms are more likely to stem from a primary pathology.

Parkinson’s dementia is not like, Alzheimer's dementia, for example, where we actually have new and emerging therapies. It's not necessarily going to respond to cholinesterase inhibitors, though we do incorporate them at times. When dealing with [patient complaints] such as mobility changes, urinary challenges, constipation….you’re trying to understand the role that the dementing process…the delirium is playing. It's a clinical challenge that is [sometimes difficult] to help patients and their families understand.