Comorbid medical illness in psychiatric patients.

Patients with psychiatric illnesses may be at higher risk for the development of certain medical problems. Those with more severe psychiatric illnesses may encounter barriers to promoting good health and to obtaining good health care when comorbid illnesses do occur. This paper reviews some of the recent literature on health care practices and health system access for the mentally ill; HIV care and its relationship to mental disorders; drug interactions between general medical drugs and psychotropics; and certain medical conditions that appear to co-occur more frequently with psychiatric disorders.

Medical illness in patients with schizophrenia.

Research into the relationship between physical illness and schizophrenia has revealed that patients with schizophrenia may be at decreased risk for certain disorders, such as rheumatoid arthritis and allergies, but at increased risk for others, including substance abuse and polydipsia. Although such knowledge may ultimately help determine the underlying causes of schizophrenia, the principal concern of practicing clinicians should be to diagnose and treat medical comorbidity in individual patients. Nearly 50% of patients with schizophrenia have a comorbid medical condition, but many of these illnesses are misdiagnosed or undiagnosed. A fragmented health care system, lack of access to care, patient inability to clearly appreciate or describe a medical problem, and patient reluctance to discuss such problems all contribute to the lack of attention to medical problems in patients with schizophrenia. Psychiatrists and primary care practitioners who treat patients with schizophrenia should make an effort to uncover medical illnesses by using a structured interview or routine physical examination whenever a patient is seen for care.

Awareness, diagnosis, and treatment of depression.

OBJECTIVES: To review recent findings on the epidemiology, burden, diagnosis, comorbidity, and treatment of depression, particularly in general medical settings; to delineate barriers to the recognition, diagnosis, and optimal management of depression in general medical settings; and to summarize efforts under way to reduce some of these barriers. DESIGN: MEDLINE searches were conducted to identify scientific articles published during the previous 10 years addressing depression in general medical settings and epidemiology, co-occurring conditions, diagnosis, costs, outcomes, and treatment. Articles relevant to the objective were selected and summarized. CONCLUSIONS: Depression occurs commonly, causing suffering, functional impairment, increased risk of suicide, added health care costs, and productivity losses. Effective treatments are available both when depression occurs alone and when it co-occurs with general medical illnesses. Many cases of depression seen in general medical settings are suitable for treatment within those settings. About half of all cases of depression in primary care settings are recognized, although subsequent treatments often fall short of existing practice guidelines. When treatments of documented efficacy are used, short-term patient outcomes are generally good. Barriers to diagnosing and treating depression include stigma; patient somatization and denial; physician knowledge and skill deficits; limited time; lack of availability of providers and treatments; limitations of third-party coverage; and restrictions on specialist, drug, and psychotherapeutic care. Public and professional education efforts, destigmatization, and improvement in access to mental health care are all needed to reduce these barriers.

Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Council on Scientific Affairs, American Medical Association.

OBJECTIVE: To deal with public and professional concern regarding possible overprescription of attention-deficit/hyperactivity disorder (ADHD) medications, particularly methylphenidate, by reviewing issues related to the diagnosis, optimal treatment, and actual care of ADHD patients and of evidence of patient misuse of ADHD medications. DATA SOURCES: Literature review using a National Library of Medicine database search for 1975 through March 1997 on the terms attention deficit disorder with hyperactivity, methylphenidate, stimulants, and stimulant abuse and dependence. Relevant documents from the Drug Enforcement Administration were also reviewed. STUDY SELECTION: All English-language studies dealing with children of elementary school through high school age were included. DATA EXTRACTION: All searched articles were selected and were made available to coauthors for review. Additional articles known to coauthors were added to the initial list, and a consensus was developed among the coauthors regarding the articles most pertinent to the issues requested in the resolution calling for this report. Relevant information from these articles was included in the report. DATA SYNTHESIS: Diagnostic criteria for ADHD are based on extensive empirical research and, if applied appropriately, lead to the diagnosis of a syndrome with high interrater reliability, good face validity, and high predictability of course and medication responsiveness. The criteria of what constitutes ADHD in children have broadened, and there is a growing appreciation of the persistence of ADHD into adolescence and adulthood. As a result, more children (especially girls), adolescents, and adults are being diagnosed and treated with stimulant medication, and children are being treated for longer periods of time. Epidemiologic studies using standardized diagnostic criteria suggest that 3% to 6% of the school-aged population (elementary through high school) may suffer from ADHD, although the percentage of US youth being treated for ADHD is at most at the lower end of this prevalence range. Pharmacotherapy, particularly use of stimulants, has been extensively studied and generally provides significant short-term symptomatic and academic improvement. There is little evidence that stimulant abuse or diversion is currently a major problem, particularly among those with ADHD, although recent trends suggest that this could increase with the expanding production and use of stimulants. CONCLUSIONS: Although some children are being diagnosed as having ADHD with insufficient evaluation and in some cases stimulant medication is prescribed when treatment alternatives exist, there is little evidence of widespread overdiagnosis or misdiagnosis of ADHD or of widespread overprescription of methylphenidate by physicians.

Liver transplantation using living donors. Preliminary donor psychiatric outcomes.

Twenty liver transplantations to sick infants from living-donor relatives were performed over a 16-month period. Before the operation, donors were screened psychiatrically by interview and psychological testing. Donor outcomes were assessed postoperatively to evaluate adverse psychiatric outcomes and to attempt a correlation with preoperative findings. There were three significant donor problems in the immediate postoperative period, two marital dissolutions and one adjustment disorder, as well as several other minor problems. These results are examined in light of past observations about living-donor renal transplantations and pediatric transplantation in general.

Acute iron intoxication in pregnancy: case report and review of the literature.

Limited reports exist regarding acute iron intoxication during pregnancy. The maternal and fetal effects of accidental or deliberate ingestion of large amounts of iron may be catastrophic. A case report of acute iron intoxication, management strategies, and a review of the literature are presented. The cornerstones of effective therapy are aggressive management with emesis induction or gastric lavage, bicarbonate instillation, vigorous intravenous hydration, and chelation therapy with deferoxamine.

Refusing to terminate a life-threatening pregnancy.

A 17-year-old single, Hispanic woman with congenital class III heart disease was found to be 15 weeks pregnant at a clinic visit where she presented in mild failure. She discussed her wish to continue with the pregnancy, knowing it might very well kill her, and plans for her infertile sister to raise the child should she die. The patient's initial refusal and subsequent agreement with the doctor's and family's wish that she terminate the pregnancy is reviewed in the context of adolescent pregnancy and the personal meaning to the patient of the pregnancy and the consultant's intervention. The case was discussed at a consultation-liaison case conference.

Psychiatric consultation in a teaching nursing home.

The first 60 psychiatric consultations provided to a university-affiliated teaching nursing home are reviewed. All patients seen had a diagnosable mental disorder, and over 40% suffered from major affective illness. Consultation resulted in a critical change in diagnosis and management in more than one-third of patients. The authors discuss the benefits and drawbacks of psychiatric consultation for nursing home patients, staff physicians, and the psychiatrists themselves.

Assessment and management of dementia in the nursing home.

Well over half of the nursing home residents in the United States suffer from dementia, and the absolute number of those affected is expected to increase dramatically. Dementia is a clinical syndrome for which physicians assess patients carefully to search for reversible etiologies and other factors which worsen cognitive function. Behavioral and affective symptoms are common and may be understood as having organic, environmental, psychological, and interpersonal components. Patients with dementia may benefit from judicious use of psychotropics but are often highly vulnerable to adverse effects. Specialized treatment units are showing early promise.

Hypomania related to phenelzine and isoetharine interaction in one patient.

A case is reported of a man with apparent unipolar depression that was responsive to treatment with phenelzine who became hypomanic when isoetharine was added to treat his chronic obstructive pulmonary disease. The role of beta-adrenergic receptors in affective illness is reviewed in light of this case.

Depression in intensive care units.

There is thought to be a high incidence of depression in intensive care units (ICUs), both as a result of the psychological toll of serious illness and threat to life as well as the physiologic derangements caused by illnesses and treatments. The authors outline a strategy to classify ICU depressions into major depressive illness, adjustment disorders, dysthymic disorder, or organic affective syndrome. Other psychiatric disturbances which may simulate depression are also discussed. A summary of environmental, behavioral, psychotherapeutic, and psychopharmacologic treatments for these disorders and their special application in the ICU setting is presented. The limitations and precautions with antidepressant drugs in this clinical site are reviewed.

Monoamine oxidase inhibitors and tricyclic antidepressants: comparison of their cardiovascular effects.

The cardiovascular effects of monoamine oxidase inhibitors (MAOIs) are contrasted with those of the tricyclic antidepressants (TCAs). At therapeutic doses, MAOIs lower supine blood pressure and increase the postural fall in blood pressure, whereas TCAs have only the latter effect. MAOIs have little effect on heart rate and do not prolong cardiac conduction; TCAs increase heart rate and prolong cardiac conduction. Neither class of drugs appears to impair cardiac mechanical functioning. For patients with certain cardiac problems, MAOIs may have an advantage over TCAs.

Depression in the spouses of demented patients.

The authors present three cases of depression requiring hospitalization in spouses of patients with progressive dementia. They discuss the stress of caring for demented people and the need for clinicians to inquire about depressive symptoms in care givers.

Protothecosis in the southeastern United States.

A case of olecranon bursitis due to the achlorophyllic algae Prototheca species in an otherwise healthy 74-year-old man prompted our review of reported cases occurring in the southeastern United States. Most cases have involved the olecranon bursa, have occurred in otherwise healthy individuals, and were cured by simple excision. Intensive therapy with amphotericin B has been used successfully in a few cases that required systemic antibiotic therapy. The histologic features of this infection are predominantly those of granulomatous inflammation, with relatively easy demonstration of organisms using routine fungal stains.