A review of brief individual psychotherapies.

The authors review and contrast four brief individual psychodynamic psychotherapies: focal, anxiety-provoking, time-limited, and broad-focus. They also summarize the techniques associated with two other brief individual psychotherapies that rely less on psychodynamic techniques: interpersonal psychotherapy and cognitive therapy. They find that differences among the therapies in the timing and type of interventions are at times more striking than the differences in their goals or identified problem areas. The authors also discuss educational and cost/benefit issues associated with the brief psychotherapies and recommend further empirical studies to determine the most effective brief therapy for selected psychiatric disorders.

A modest proposal for consultation/liaison psychiatry in the 1980s.

The authors discuss how consultation/liaison psychiatry has promoted closer cooperation between primary care and psychiatry in the general hospital setting and has increased physician concern for psychosocial issues while at the same time creating financial and organizational problems for consultation/liaison programs. To remedy these difficulties, the authors propose that all general hospitals that have more than 350 beds have fully staffed consultation/liaison services and that these services be funded through third-party reimbursement formulas as an integral hospital-based service. They outline six potential benefits of their proposal and suggest that action must be taken now if consultation/liaison psychiatry is not to suffer the same fate as the community mental health center movement.

New approaches in the pharmacotherapy of posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) may develop after exposure to severe stress, such as combat, accidents, assaults, and natural disasters. Pharmacotherapy can be a useful adjunct in the comprehensive treatment of these patients. The presence of comorbid conditions, including depression, panic disorder, substance abuse, and traumatic brain injury, should be carefully evaluated. Symptoms of PTSD that are associated with central nervous system hyperarousal or reexperiencing of the traumatic event appear to be the most responsive to pharmacotherapy. Social withdrawal and dulled responsiveness have not been shown to be alleviated through standard pharmacologic interventions. A therapeutic strategy is proposed that is based on the patient's symptoms and initial response to medication.

Psychopharmacology of depression in neurologic disorders.

Depression occurs frequently in patients with neurologic disorders. Current research in traumatic brain injury, stroke, Parkinson's disease, multiple sclerosis, epilepsy, and brain tumors indicates that affective symptomatology can be a specific sequel of these illnesses that is related to the resultant impairment in brain functioning. Because of the cognitive and emotional deficits that neurologic disorders can cause, the clinician must be aware of the complicated presentation of depression in these patients. Psychopharmacologic treatments are safe and efficacious in the treatment of depression in patients with neurologic illness.

Pharmacologic management of aggression in the elderly.

Issues related to the epidemiology, nosology, and differential diagnosis of organic aggressive disorders in the elderly are discussed. Rating and monitoring of aggressive events using the Overt Aggression Scale are reviewed. The management of acute aggression with antipsychotic agents and benzodiazepines is presented, as well as an approach for using beta-blockers, anticonvulsant agents, and serotonin-specific antidepressants and an antianxiety agent for the treatment of chronic aggression.

A treatment algorithm for the management of anxiety in primary care practice.

Patients frequently present to primary care physicians with somatic symptoms that mask an underlying anxiety disorder. As a result, unnecessary diagnostic tests are ordered, and inappropriate medications are prescribed. Psychiatrists may help improve their primary care colleagues' ability to identify and treat these anxiety disorders. This paper reviews the adverse effects of untreated anxiety in managed care settings and outlines a treatment algorithm that psychiatrists may wish to use to assist primary care physicians in the cost-efficient, pharmacologic treatment of anxiety disorders in their patients.

Pharmacologic approach to management of agitation associated with dementia.

Dementia is a complex syndrome associated with cognitive impairment, personality change, and behavioral disturbance. Behavioral symptoms frequently present the greatest challenge for caregivers and are often the determining factor in institutional placement. Determining the need for pharmacologic treatment of an agitated patient requires considering the full range of biopsychosocial variables and ultimately involves assessing the risks and benefits of the medications selected for the patient. In this article, the phenomenology of agitation is reviewed along with the pharmacologic treatment of agitation in patients with dementia, including the use of benzodiazepines, neuroleptics, beta-adrenergic-blocking agents, serotonergic agents, carbamazepine, and lithium.

Cost-effectiveness of newer antidepressants compared with tricyclic antidepressants in managed care settings.

BACKGROUND: Our aim was to determine the cost-effectiveness of newer antidepressants compared with tricyclic antidepressants in managed care organization settings. METHOD: We employed cost-utility analysis based on a clinical decision analysis model derived from published medical literature and physician judgment. The model, which represents ideal primary care practice, compares treatment with nefazodone to treatment with either imipramine or fluoxetine or to a step approach involving initial treatment with imipramine followed by nefazodone for treatment failures. The outcome measures were lifetime medical costs, quality-adjusted life years (QALYs), and costs per QALY gained. RESULTS: The base case analysis found that nefazodone treatment had $16,669 in medical costs, compared with $15,348 for imipramine, $16,061 for the imipramine step approach, and $16,998 for fluoxetine. QALYs were greatest for nefazodone (14.64), compared with 14.32 for imipramine, 14.40 for the step approach, and 14.58 for fluoxetine. The cost-effectiveness ratio comparing nefazodone with imipramine was $4065 per QALY gained. The cost-effectiveness ratio comparing nefazodone with the step approach was $2555 per QALY gained. There were only minor differences in costs and outcomes between nefazodone and fluoxetine, with nefazodone resulting in $329 fewer costs and 0.06 more QALYs. The cost-effectiveness ratios comparing fluoxetine with imipramine and with the step approach were $6346 per QALY gained and $5206 per QALY gained, respectively. In the sensitivity analyses, the cost-effectiveness ratios comparing nefazodone and imipramine ranged from $2572 to $5841 per QALY gained. The model was most sensitive to assumptions about treatment compliance rates. CONCLUSION: The findings suggest that nefazodone is a cost- effective treatment compared with imipramine or fluoxetine treatment for major depression. Fluoxetine is cost-effective compared with imipramine treatment, but is estimated to have slightly more medical costs and less effectiveness compared with nefazodone. The basic findings and conclusions do not change even after modifying key model parameters.

Psychopharmacologic approach to the medically ill patient.

Generally, there are few absolute contraindications to the use of somatic psychiatric therapies in the medically or surgically ill. A knowledge of psychotropic drugs, of their predictable effects on organs, of their interactions with other medications, and of the idiosyncratic reactions that they often produce allows the consultation psychiatrist to treat the seriously ill patient safely. Close collaboration with other consultants is essential to maximize therapeutic benefits.

Psychopharmacologic issues in the diagnosis and treatment of organic mental disorders.

The psychiatrist in a medical setting must have in-depth knowledge in three specific areas. It is vitally important that he or she be able to recognize organic mental disorders caused by medical conditions and medications. The psychiatrist should also be thoroughly familiar with the appropriate psychotropic medications available to treat these disorders. Finally, a knowledge of frequent drug interactions and the limitations of psychoactive medications in treating psychiatric symptoms is invaluable.

Research on the biologic aspects of violence.

Violent behavior is reviewed in regard to its relationship with genetic, hormonal, neurochemical, electrical, substance abuse, and psychiatric factors. The most significant relationships were found between violent behavior and the neurotransmitter serotonin. Suggestive associations were found between violent acts and testosterone serum levels, epilepsy, and episodic dyscontrol.

Recognition and treatment of acute alcohol withdrawal syndromes.

The alcohol withdrawal syndromes are generally self-limited processes from which spontaneous recovery can be anticipated. To achieve this outcome, the various types of withdrawal must be managed in such a way as to prevent the occurrence of life-threatening situations. This begins with a good initial evaluation, followed by the appropriate pharmacologic and behavioral steps to control the severity of withdrawal symptoms and to manage complications. Once the withdrawal process is completed, the patient can then be entered into a long-term treatment program.

The benefits of a psychiatric consultation--liaison service in a general hospital.

In this period of increased governmental regulation and decreased reimbursement for psychiatric services by third-party carriers, a fully staffed and financially stable psychiatric consultation-liaison service in the general hospital may still generate significant benefits for patients, hospital administrators, and psychiatrists: an increased rate of diagnosis of psychiatric and medical disorders, a reduction in the length of stay of medical or surgical patients, a decreased utilization of medical services and the development of innovative consultation-liaison activities. This article summarizes these benefits and outlines training obstacles that must be overcome to increase cooperation between psychiatry and medicine so that these benefits may be realized.

Primary care in psychiatry residency training.

The author summarizes patient perspectives and government initiatives that have fostered closer medicine-psychiatry cooperation and more comprehensive treatment of patients. Despite the growing numbers of people requiring more formal mental health care, most patients are being treated by primary health care providers. This trend will continue as long as there is a decline in the number of medical students entering psychiatry. The author summarizes several general principles that psychiatry residency program directors should consider in designing primary care experiences for their residents and for medical students rotating on their services: longitudinal primary care experiences in organized medical care settings, training in basic medical principles and techniques, and instruction in the biopsychosocial model of disease. The author also recommends there specific training experiences for psychiatry residents that would enhance their ability to provide more effective mental health services to primary care physicians and their patients: consultation psychiatry, primary mental health care, and general psychiatry. The author concludes that medical students, through their contact with primary care-oriented psychiatry residency programs, would be more attracted to psychiatry as a specialty choice and that residents, upon completion of training, would be more inclined to practice in primary care settings.

Compliance with psychiatric referrals from a general hospital psychiatry outpatient clinic.

This study examines the referral patterns of 949 patients seen in a general hospital psychiatry outpatient clinic during a 15-month period. One hundred patients referred to outpatient psychotherapists were interviewed by telephone to determine compliance rates with referral recommendations. Forty-five percent reported compliance with the referral, defined as attendance at one or more psychiatric follow-up visits. Factors associated with higher compliance rates were being married, being referred at the initiation of the therapist and not the patient, and, for a subgroup of patients, receiving a list of potential psychotherapists. Neither diagnosis nor severity of illness predicted compliance, and self-referral was not associated with improved compliance. There was also no relationship found between satisfaction with the referral procedure and subsequent compliance with the referral. In 49% of the noncompliant cases, reasons cited were a self-perceived lack of need for continuing treatment due to symptom resolution and insufficient motivation.

A reexamination of the psychiatric resident's experience in the general hospital.

The authors discuss three phases of psychiatric residency training: the beginning psychiatry training syndrome, the professional and psychologic changes associated with the second year, and the senior resident year, characterized by transition to practice issues. Since most residency training experiences occur in general hospital settings, it is imperative that general hospital psychiatrists be aware of the professional and emotional changes that residents experience as they move from inpatient to outpatient settings and assume more administrative responsibilities in departments of psychiatry. The authors recommend preventive steps that residency training directors in general hospitals might take to reduce residents' adverse emotional responses to stresses associated with each training period in the general hospital.

Teaching psychosocial issues to medical house staff: a liaison program on an oncology service.

In a one-year controlled study, the authors assessed the impact of an active consultation-liaison teaching program on the attitudes of medical house officers toward psychosocial issues related to the care of oncology patients, consultation-liaison psychiatry, and its importance for them and their patients. Fifty medical interns, residents, and fellows, divided into a test group (N = 25) and a control group (N = 25), were followed during a one year period. A 52-item questionnaire was administered to test group subjects before and after a one- to two-month clinical rotation on the hematology/oncology service, and to the control group members at similar intervals. After their experience with consultation-liaison psychiatry, the test group members showed a significant positive change in the importance they placed upon psychiatric consultations, case presentations and the role of psychiatrists in the development of their attitudes toward the psychological care of cancer patients. The house officers also recorded significant positive changes in their attitudes toward the effectiveness and role of the consultation-liaison service in educating and assisting them in learning more about psychosocial issues. The control group demonstrated no significant change.

An evaluation of patients who received an organic mental disorder diagnosis on a psychiatric consultation-liaison service.

The authors conducted comprehensive medical record reviews of 100 medical and surgical patients who received an organic mental disorder diagnosis by the Psychiatry Consultation-Liaison (C/L) Service of a large teaching hospital. The cases were randomly selected from among 182 patients with an organic mental disorder diagnosis, who, in turn, were drawn from 1085 consecutive psychiatric consultations conducted during a 1-year period. Dementia (34%) and delirium (32%) constituted the most common diagnoses. Approximately 78% of the patients were noted to have laboratory abnormalities (2.7 per patient), three quarters of which were routine tests. The mean age of patients without laboratory abnormalities (47.6 years) was 15 years younger than those with abnormal findings (62.6 years). The patients averaged 5.7 medications, with delirious patients averaging 7 medications and those with dementia, 4.5, a statistically significant difference. Patients with no laboratory abnormalities were receiving less medication (2.6) than those with abnormalities (6.5).

Psychiatric consultations in a military general hospital. A report on 1065 cases.

The authors describe the demographic and diagnostic characteristics of 1065 medical and surgical inpatients referred for psychiatric consultation over a 1-year period at a military medical center. The referral rate was 5.8% of all hospital admissions with the percentage of referrals from surgical and neurology services being higher than recent civilian studies. Although the variety and frequency of psychiatric and physical disorders are quite similar to civilian consultation-liaison (C/L) psychiatric services, the authors reported lower rates of personality disorder diagnoses and higher percentages of V code and no-psychiatric-disorder diagnoses.

Inpatient participation in treatment planning: a preliminary report.

This study investigated the effect of patient participation in treatment planning conferences (TPCs) upon length of hospitalization and upon the frequency of military soldiers being returned to duty. Patients with major affective disorders and schizophrenic disorders showed an 8.2% decrease in hospital stay whereas patients with minor affective disorders, personality disorders, substance abuse, and adjustment disorders showed a 98.8% increase. Additionally, the percentage of active duty soldiers with a major depressive episode who were returned to duty increased significantly when they participated in their TPC.