Adjustment disorder: a multisite study of its utilization and interventions in the consultation-liaison psychiatry setting.

The consultation-liaison (C-L) psychiatry services of seven university teaching hospitals in the United States, Canada, and Australia (the MICRO-CARES Consortium) used a common clinical database to examine 1039 consecutive referrals. A diagnosis of adjustment disorder (AD) was made in 125 patients (12.0%); as the sole diagnosis, in 81 (7.8%); and comorbidly with other Axis I and II diagnoses in 44 (4.2%). It had been considered as a rule-out diagnosis in a further 110 (10.6%). AD with depressed mood, anxious mood, or mixed emotions were the commonest subcategories used. AD was diagnosed comorbidly most frequently with personality disorder and organic mental disorder. Sixty-seven patients (6.4%) were assigned a V code diagnosis only. Patients with AD were referred significantly more often for problems of anxiety, coping, and depression; had less past psychiatric illness; and were rated as functioning better--all consistent with the construct of AD as a maladaptation to a psychosocial stressor. Interventions were similar to those for other Axis I and II diagnoses, in particular, the prescription of antidepressants. Patients with AD required a similar amount of clinical time and resident supervision. It is concluded that AD is an important and time-consuming diagnostic category in C-L psychiatry practice.

Organic mental disorders in the consultation-liaison psychiatry setting. A multi-site study.

Interventions recommended by consultation-liaison psychiatrists for inpatients they diagnosed as having DSM-III-R organic mental disorder (OMD) were studied to see to what extent specific variables distinguished the OMD patients and differentiated the subgroups of patients with OMD. Prospective data and Mini-Mental State Exam (MMSE) scores on 625 consecutive referrals at 3 general hospitals in Australia and the United States were collected by using the MICRO-CARES database system. The OMD group differed from the other patients because they were significantly more likely to have been referred for "organic brain syndrome" or "agitation," had less mood disorder and lower MMSE scores, and received more recommendations for antipsychotics and for ward-environment manipulation and fewer recommendations for psychological management. The many differences among the OMD subgroups were also consistent with their DSM constructs. A pilot exploration of the validity of the DSM-IV constructs of cognitive disorder and its subgroups performed on the redistributed data suggested that these constructs have similar usefulness.

The multisite field trial of the consultation-liaison psychiatry assessment instrument.

A multisite field trial was conducted at 11 institutions to test the clinical reliability of a 29-item consultation-liaison (C-L) psychiatry assessment instrument. Twenty-five raters viewed videotapes of two "trainees" conducting clinical interviews with a simulated patient. One trainee was a medical student, the other was a fellow in psychiatry. Raters completed the 29-item assessment instrument for each trainee. The mean value scores reflected the skill of each trainee. The medical student had a mean score of 1.93, whereas the C-L fellow had a mean score of 3.13 which parallels the expected level of skill for the two interviewers. Eighty-six percent of the items (25/29) had a standard deviation (SD) of less than 1.0. Each of the remaining four items (14%) had a SD minimally greater than 1.0. These results reflect clear wording of items with measurable parameters defined for assessing trainees' skills. The authors present different uses for the assessment instrument, including giving feedback to trainees regarding interviewing techniques and skills; setting "gold" and "lead" standards for clinical C-L interviewing skills; and training supervisors in evaluation using a standardized assessment instrument.

Psychiatric comorbidity among hospitalized AIDS patients vs. non-AIDS patients referred for psychiatric consultation.

Data were collected on 3,420 psychiatric consultations from July 1, 1989, to January 1, 1994, of which 675 were for patients identified as infected with the human immunodeficiency virus (HIV). Comparisons of psychiatric comorbidity among persons with AIDS (PWAs), HIV+ asymptomatic patients, and non-HIV patients were made. Dementia was a significantly frequent comorbid diagnosis among the referred PWAs compared with the general consultation population and was related to older age. Psychiatric comorbidity among the referred HIV+ asymptomatic patients more closely resembled the general consultation population. Major depression was relatively rare among the PWAs. The authors believe that the large sample size of this study allows for an accurate representation of the psychiatric disorders found among medically ill HIV patients in an urban hospital who are referred for psychiatric consultation.

AIDS anxiety among health care professionals.

House staff physicians and nurses at a major New York City teaching hospital completed a 79-item questionnaire designed to assess AIDS anxiety, fear of contagion, and personal attitudes about homosexuality. Sixty-three percent of respondents were skeptical of or did not believe assurances by experts that health care workers who observe safety guidelines are at minimal risk of contracting AIDS from patients. Respondents from minority groups were significantly less trusting of experts' reassurances of their safety and were more uncomfortable working with homosexual patients. Twenty-six percent of all respondents feared that they would become victims of AIDS if they continued their present work, yet 97 percent expressed a firm commitment to caring for AIDS patients throughout their illness and the dying process. The author suggests that AIDS training and educational programs for health care professionals should consider their cultural background and psychosocial needs.

Defining the psychiatric role in spastic dysphonia.

The authors evaluated 11 surgically-treated patients with spastic dysphonia, a phonation disorder of unclear etiology. The results indicate that the illness does not appear to be a somatoform disorder, but that stress may play a role in its expression, and that there may be secondary depression and anxiety. The experience of spastic dysphonics suggests that psychiatric treatments may be inappropriately applied to an illness without clear organic etiology, whereas, conversely, a proper psychiatric role may be rejected when effective medical or surgical treatment is available. The authors recommend that psychiatrists evaluating patients with illnesses of unclear etiology should be cautious in making a primary psychiatric diagnosis unless DSM-III criteria are met.

Liaison psychiatry-otolaryngology rounds.

In an attempt to define and resolve patient and staff needs with regard to the psychological, social and economic problems in clinical otolaryngology, psychiatry/otolaryngology rounds were established in the Department of Otolaryngology 18 months ago. These weekly rounds have contributed greatly to improved patient care and better physician-nurse relations. They have also served a significant educational role for residents, medical students and other members of the patient care team. At present the rounds are attended by the inpatient nursing staff, 2 physicians, 6 residents, 3 medical students, an otolaryngologic social worker and the liaison psychiatrist. The meeting begins with a 10 minute discussion and review of current problems among the staff. Attention is then directed to the patient who will be interviewed for the day. The medical and social history are presented. Then the patient is brought in and interviewed in a non-stressful session for 20 minutes. After the patient leaves, the staff discusses the problems which the patient has encountered or poses to them, and the conference participants formulate an appropriate therapeutic plan. Among the problems which have been discussed are noncompliance, organic mental syndromes, hypochondirasis, depression, death and dying, disfigurement, loss of bodily function, and chronic pain. For those patients in whom further psychiatric evaluation and treatment are deemed necessary, the psychiatrist becomes an active participant in their clinical care.