Psychiatric consultation education--1976.

The teaching of consultation liaison (CL) psychiatry to psychiatric residents, medical students, and other trainees is reported from 92 medical schools, representing 81% of those surveyed with a one-page questionnaire. Psychiatric residency programs devote approximately 10% of their time to CL training, a slight increase over the percentage ten years ago. Approximately 35% of medical students in programs from which we received responses have some consultation CL education, although this varies from a few seminars to an eight-week full-time rotation. Other trainees receiving CL experience include nonpsychiatric residents and interns (22 programs), psychologists (18), nurses (12), and social workers (5). Program directors report an approximately 90% "favorable" reaction to such training by all trainees. Consultation liaison training for residents still represents a small portion of their entire experience. A surprisingly large percentage of medical students are exposed to CL education, but with tremendous variation in that exposure. Other trainees are not heavily involved in CL programs, indicating a possible future expansion of integrated psychosomatic teaching. The data presented should serve as a comparative baseline for future program design.

Depressed mood and survival in seriously ill hospitalized adults. The SUPPORT Investigators.

OBJECTIVES: To assess the relationship among depressed mood, physical functioning, and severity of illness and to determine the relationship between depressed mood and survival time, controlling for severity of illness, baseline functioning, and characteristics of patients. METHODS: Prospective cohort study of data for 3529 seriously ill hospitalized adults who received care at 5 tertiary care teaching hospitals and who completed a depressed mood assessment 7 to 11 days after admission to the study. The Profile of Mood States depression subscale was used to assess depressed mood. A stratified Cox proportional hazards model was used to assess the independent effect of depressed mood on survival time, adjusting for demographic characteristics of patients and health status. RESULTS: Greater magnitudes of depressed mood were associated with worse levels of physical functioning (r = 0.151; P < .001) and more severity of illness. Depressed mood was associated with reduced survival time after adjusting for patient demographics and health status (hazards ratio, 1.134; 95% confidence interval, 1.071-1.200; P < or = .001). CONCLUSION: Seriously ill patients should be assessed for the presence of depressed mood even if they have not been given a diagnosis of depression. Further study is needed to determine whether interventions aimed at relieving depressed mood may improve prognosis.

EEG observations during combined haloperidol-lithium treatment.

Some reports have indicated a neurotoxic interaction of haloperidol and lithium, whereas others have not found this interaction. This is a report on two patients who showed both photomyoclonic and photoparoxysmal responses while on combined lithium-haloperidol treatment. We suggest that these findings, which have not been previously reported to be associated with combined lithium-haloperidol treatment, reflect neurotoxicity and that electroencephalogram (EEG) monitoring should be done on patients receiving this combined medication regimen.

Serum creatine phosphokinase levels in patients meeting the St. Louis research diagnostic criteria for schizophrenia.

In this study 18 patients with a research diagnostic criteria diagnosis of schizophrenia had a mean initial serum creatine phosphokinase level significantly higher than that of 36 control subjects with other RDC diagnoses. There were no corresponding elevations in the serum levels of nondrinking alcoholics or patients with primary or secondary affective disorders. The authors suggest that increased creatine phosphokinase levels in schizophrenic patients may be due to a sudden increase in the substance in the dopaminergic or limbic system due to increased muscle membrane permeability or to sympathetic nervous system or adrenergic dominance.

Low-dose oral medroxyprogesterone acetate in the management of the paraphilias.

BACKGROUND: There are no reports on the use of low-dose oral medroxyprogesterone acetate (MPA) in the treatment of the paraphilias. High-dose depot MPA treatment (500-800 mg i.m. weekly) has proven to control the behavioral manifestations of the paraphilias when testosterone levels decrease from pretreatment to prepubescent levels, but at the price of significant morbidity. METHOD: Oral MPA (60 mg/day for an average of 15.33 months) was given in an open nonblind trial to seven patients who met criteria for DSM-III-R paraphilias. Four of the subjects had shown inadequate improvement after 1 year of psychotherapy. RESULTS: Six subjects responded at 60 mg/day. Testosterone levels decreased by 50% to 75% (range, 100-400 ng/dL). No patient displayed significant side effects. All patients described significantly fewer paraphilic fantasies, and no patient reported engaging in paraphilic behaviors during oral MPA treatment. CONCLUSION: Double-blind placebo and phallometrically controlled tumescence studies need to be carried out to test the results of this study.

Evaluation of studies on platelet alpha 2 adrenoreceptors in depressive illness.

Discrepant results have been reported from at least ten laboratories regarding the status of platelet alpha 2 adrenoreceptors in depressed patients. Using a statistical test to combine those studies which utilized radioligand binding techniques, we find the overall data support an elevation in density of platelet alpha 2 adrenoreceptors from drug-free depressed patients (p less than 0.05) and suggest a normalization to lower binding values following antidepressant drug treatment (0.05 less than p less than 0.10). However, these positive results are attributable to highly significant findings by only three laboratories. Much of the discrepancy may be attributable to numerous methodological variables which distinguish the studies. Foremost amongst these variables are the use of different platelet size populations, the use of different medium, and the choice of radioactive ligand and competitor (non-radioactive ligand) in the assay. We present a rationale for the proper choice of each methodological condition used in the clinical assessment of platelet alpha 2 adrenoreceptor status, hoping that improved experimental designs will resolve the current controversy.

Delirium after cessation of glucocorticoid therapy.

We report here a case of delirium that occurred after discontinuation of glucocorticoid therapy. Administration of hydrocortisone reversed the mental status changes seen in this patient. We review similar reported cases and discuss the direct actions of glucocorticoids on the brain.

Reverse liaison rounds with a burn unit case.

A liaison rounds is presented, one attended by all members of a consultation-liaison (C-L) team along with the medical director of a burn unit. This structure is designated as a "reverse liaison rounds," as it is the opposite of the conventional liaison meeting, which consists of one C-L consultant and the total nonpsychiatric team. The content centered on a self-inflicted burn case in which countertransference issues involved a nonpsychiatrist. The unconventional format of the reverse liaison rounds provided all parties with new knowledge, perspectives, and insights into the interactions between the C-L consultant and the burn unit team.

Liaison psychiatry on a burn unit.

Psychiatric liaison activities and intervention on a burn unit are described. The authors review the psychiatrist's interventions with regard to unhealthy staff denial; educating staff about psychiatric issues; facilitating improved staff-patient communication; and helping nurses manage patients' inappropriate sexual behavior.

Impact of the interaction of depression and physical illness on a psychiatric unit's length of stay.

Prior literature suggests that length of stay (LOS) on medical inpatient units is increased by the coexistence of depression and physical illness. The present study examined 532 psychiatric inpatient admissions to determine if physical illness increased LOS for patients grouped by diagnostic categories of psychosis, depression, personality disorder, anxiety disorder, adjustment disorder, bipolar disorder (not depressed), and other psychiatric disorders. LOS for depressed patients was significantly longer for those with any physical final diagnosis (mean = 20.08 days) than for depressed patients with no physical diagnosis (mean = 11.48 days). LOS was also longer for all patients with physical diagnoses (mean = 19.31 days) than all patients with no physical diagnosis (mean = 13.13 days). No other specific diagnostic group (psychosis, personality disorder, and so forth) showed significant differences in LOS for any associated physical illness vs no physical illness. The study results tend to indicate that physical illness is associated with increased LOS for depressed psychiatric patients but not for other specific diagnostic groups. Depressed patients may 1) mask physical illness by depression-generated physical complaints; 2) prioritize mood symptoms over physical symptoms; and/or 3) may suffer from feelings of hopelessness or be pessimistic that their physical symptoms will be effectively treated and, therefore, not report their physical symptoms.

Effect of liaison psychiatry on attitudes toward psychiatry, rate of consultation, and psychosocial documentation.

Prior literature suggested that psychiatric liaison on medical wards would produce a more positive attitude towards psychiatry, more psychosocial chart documentation, and a higher consultation request rate. Over 3 years, liaison was conducted on two medical wards, and its effect was contrasted with two control (consultation only) medical wards. Liaison activities were more favorably received by consultees than consultation alone and increased the consultation request rate, but produced no change in psychosocial documentation. Additional effectiveness of liaison activities might be achieved through direct, focused interventions, and through active involvement of senior medical faculty.

Decrease of depression during stroke and amputation rehabilitation.

Clinical observation had suggested that mild depression occurs after admission for acute medical treatment and then decreases during further hospitalization for rehabilitation treatment. The Geriatric Depression Scale (GDS) was given on admission and discharge to 14 stroke and 17 amputee rehabilitation patients. Each of the two groups showed decreasing GDS scores from beginning to end of the rehabilitation admission. Suggested reasons included: (1) the gradually diminishing effects of stroke and amputation as life crises during the 1-2 month admission, (2) effects of physical improvement on mood and affect, (3) milieu effects of the medical ward, and (4) tendencies for all psychopathology scale scores to decrease on retest.

Physical consequences of depression in the stroke patient.

The past literature suggests the hypothesis that depression is associated with decreased physical functional ability in stroke patients. On a medical rehabilitation ward, 21 stroke patients were evaluated for depression by psychiatric interview and self-report, and were also rated on the Barthel's Functional Index (BFI). The hypothesis was supported: Patients scoring 17 or higher on the Beck Depression Inventory (BDI) (N = 7) had lower initial scores on the BFI than patients with lower BDI scores. There was a trend for these seven depressed patients to improve more slowly as ascertained by the BFI. Depression was suggested to lower functional ability by increasing fatigue, hopelessness, and decreasing motivation.

Assessing residents' performance in C-L psychiatry. Work in progress.

The scores from the Psychiatry Resident In Training Examination (PRITE) provide useful information concerning residents' acquired knowledge about consultation-liaison (C-L) psychiatry. However, a comparable method for assessment of C-L residents' clinical skills has not been developed. A task force was commissioned by the Consultation-Liaison Psychiatry Section of the Association for Academic Psychiatry to develop such an assessment system. This paper presents the work of that task force and includes a methodology for assessing clinical performance, a prototype evaluation form, and instructions for its use.

Informed consent as a source of bias in clinical research.

Clinical observation suggested that schizophrenic patients more often refused to participate in experiments. In two studies psychiatric patient volunteers and nonvolunteers were compared on discharge diagnoses (psychiatric and medical), medication given, demographic measures, and hospitalization characteristics. In each study, patients with paranoid schizophrenia were more likely to refuse participation. Also, in each study, volunteers received more benzodiazepines and more nonpsychiatric medication. The latter difference could not be explained on the bases of rated severity of or probability of drug use in diagnosed medical illnesses, or number of medical illnesses. Characteristics of schizophrenic patients such as suspiciousness, negativism, and ambivalence were suggested as possible sources of their refusal to participate. Nonvolunteers were suggested to be less agreeable and compliant in general, and perhaps less likable, possibly explaining their receiving fewer benzodiazepines and nonpsychiatric medications. Attempts to characterize and correct the volunteer bias should be made, including offering tangible reward.

Child spacing effects: a comparison of institutionalized and normal children.

Data were collected on 52 psychiatrically abnormal and 101 normal children, as part of a study of the effects of sibship constellation variables on intellect, achievement, personality traits, and social adjustment. The two groups are closely equivalent with respect to age, social class (lower and lower-middle) and sibship size. There was a significantly higher percentage of psychiatrically abnormal than normal children having a sibling less than two years older. conversely, the normal children had a significantly higher percentage of widely spaced (to the next older) than did the psychiatrically abnormal children. Unwantedness by parents (especially the mother) may be a factor in increasing the likelihood of learning and behavioral difficulties and other social disarticulation.

Teaching psychiatry to medical students on a consultation service.

Medical students experience psychiatric consultation as part of their undergraduate psychiatric clerkship experience. This allows further identification of the medical student with the psychiatrist in management of psychiatric problems in patient who are primarily non-psychiatric. Reaction has tended to be favourable from the medical students without a great loss of speed or efficiency in terms of the service committment.

Alertness and clear thinking as characteristics of high naturally occurring autonomic nervous system arousal.

Studies of the effect of induced mood on the autonomic nervous system (ANS) suggested that naturally occurring mood might also covary with the ANS. Ss were 13 men and women aged 20 to 70. Fatigue, confusion, and depression were measured on the Profile of Mood States, while barometric pressure and the ANS indices of heart rate and body temperature were also recorded. Fatigue and confusion each showed negative relationships to both heart rate and body temperature. Barometric pressure showed a suggestively positive relationship to the mood of depression. Hypothalamic serotonin concentration was suggested as a central factor producing the covariations between the mood indices (alertness and clear thinking) and the ANS measures.

Family size effects: a review.

Larger families are more frequent with early marriage and rapid birth of the first child. In larger families, child rearing becomes more rule ridden, less individualized, with corporal punishment and less investment of resources. Smaller families tend to result in higher IQ, academic achievement, and occupational performance. Large families produce more delinquents and alcoholics. Perinatal morbidity and mortality rates are higher in large families as birth weights decrease. Mothers of large families are at higher risk of several physical diseases. Common methodological errors are indicated and exemplary studies are described.

Family constellation and creativity: firstborn predominance among classical music composers.

Biographies of classical musci composers were examined for family constellation information. Usable data were found for 80 composers. Firstborns, especially only children, were found significantly more frequently than in a sample of creative writers studied by Bliss. Increased frequency of firstborns was also suggested in a study of musical performers by Raychaudhuri. Classical musci composition was seen as an ability more similar to usual academic pursuits than creative writing.