Clinical and psychological course of diabetes from adolescence to young adulthood: a longitudinal cohort study.

OBJECTIVE: To determine the clinical and psychological course of diabetes through adolescence and the relationship with glycemic control in young adulthood. RESEARCH DESIGN AND METHODS: A longitudinal cohort study of adolescents recruited from the register of the outpatient pediatric diabetes clinic. A total of 76 individuals (43 male patients, 33 female patients) aged 11-18 years completed baseline assessments, and 65 individuals (86%) were reinterviewed as young adults (20-28 years of age). Longitudinal assessments were made of glycemic control (HbA(1c)), weight gain (BMI), and development of complications. Adolescents completed self-report questionnaires to assess emotional and behavioral problems as well as self-esteem. As young adults, psychological state was assessed by the Revised Clinical Interview Schedule and the self-report Brief Symptom Inventory. RESULTS: Mean HbA(1c) levels peaked in late adolescence and were worse in female participants (average 11.1% at 18-19 years of age). The proportion of individuals who were overweight (BMI >25.0 kg/m(2)) increased during the 8-year period from 21 to 54% in female patients and from 2 to 28% in male patients. Serious diabetes-related events included death in one patient and cognitive impairment in two patients. Individuals in whom diabetic complications developed (25% of male patients and 38% of female patients) had significantly higher mean HbA(1c) levels than those without complications (difference 1.9%, 95% CI 1.1-2.7, P < 0.0001). Behavioral problems at baseline were related to higher mean HbA(1c) during the subsequent 8 years (beta = 0.15, SEM (beta) 0.04, P < 0.001, 95% CI 0.07-0.24). CONCLUSIONS: The outcome for this cohort was generally poor. Behavioral problems in adolescence seem to be important in influencing later glycemic control.

Eating habits, body weight, and insulin misuse. A longitudinal study of teenagers and young adults with type 1 diabetes.

OBJECTIVE: To examine disordered eating, insulin misuse, weight change, and their relationships with glycemic control and diabetic complications in adolescents with type 1 diabetes followed up over eight years. RESEARCH DESIGN AND METHODS: Of 76 adolescents (43 male, 33 female) with type 1 diabetes aged 11-18 years at the first assessment, 65 were interviewed as young adults (aged 20-28 years). Eating habits were assessed using a standardized Eating Disorder Examination. Height and weight were determined and BMI calculated. Three consecutive urine specimens were collected for measurement of albumin/creatinine ratio and other significant diabetic complications were recorded. Glycemic control was assessed by glycated hemoglobin. RESULTS: Weight and BMI increased from adolescence to young adulthood. Females were overweight as adolescents and both sexes were overweight as young adults. Concern over weight and shape increased significantly for both sexes from adolescence to young adulthood. This increase in concern was reflected in increased levels of dietary restraint. Features of disordered eating were apparent in females at both assessments, but no patients met the criteria for anorexia nervosa or bulimia nervosa at either assessment. A total of 10 (30%) females, but none of the males admitted underusing insulin to control weight. Five (45%) females with microvascular complications had intentionally misused insulin to prevent weight gain. CONCLUSIONS: An increase in BMI from adolescence to adulthood was associated with higher levels of concern over shape and weight and more intense dietary restraint, especially among females. Overt eating disorders were no more prevalent in these patients than in the general population, but milder forms of disordered eating were common and had implications for diabetes management. Insulin omission for weight control was frequent among females and may contribute to poor glycemic control and to risk of complications.

Exercise capacity and quality of life in the treatment of heart failure.

In a double-blind study comparing two active treatments (digoxin and xamoterol) and placebo in patients with heart failure, improvements in exercise capacity and quality of life were observed in all three groups, with no significant differences. The substantial benefits seen in the placebo group were probably the result of increased attention from the medical and research staff and suggest the therapeutic value of special heart failure clinics. The relationship between exercise and symptomatic/functional status has been unclear. We developed quantitative measures of quality-of-life variables and examined their relationship with exercise capacity. There were significant relationships between change in exercise duration and changes in breathlessness, tiredness, chest pain, walking difficulty, rate of walking, difficulty with daily tasks, speed of daily tasks, mood, and sleeping. This study confirms the validity of measuring change in exercise capacity and demonstrates that specific measurements of quality of life make an important contribution to the evaluation of the treatment of heart failure.

Prediction of psychological outcomes one year after a motor vehicle accident.

OBJECTIVE: The authors' goal was to identify predictors of 1-year outcomes for consecutive patients in a hospital emergency department following motor vehicle accidents and to describe the prevalence and course of four types of psychiatric outcomes after such accidents. METHOD: Consecutive patients aged 17-69 years who attended a general hospital emergency department following a motor vehicle accident were identified. Medical information for these patients was extracted from case notes, and the patients completed self-report questionnaires at baseline (soon after the accident), 3 months after the accident, and 1 year after the accident. Measures included a self-report scale for posttraumatic stress disorder (PTSD), the Hospital Anxiety and Depression Scale, and questions about phobic travel anxiety. Logistic regression was used to examine predictors of outcome. RESULTS: Different frequencies and courses of PTSD, phobic travel anxiety, general anxiety, and depression were reported by a third of the subjects at both 3-month and 1-year follow-up. Many of the subjects reported improvements between 3 and 12 months, but others described late onset of psychiatric outcomes after the accident. There were differences in baseline and 3-month predictors of each type of 1-year outcome. CONCLUSIONS: The four types of psychiatric outcomes after a motor vehicle accident that were noted overlap, are persistent, and have different early predictors. These findings have implications for the early recognition of psychiatric consequences of motor vehicle accidents that would enable early intervention.

Childhood risk factors for adults with medically unexplained symptoms: results from a national birth cohort study.

OBJECTIVE: The purpose of this study was to test the hypothesis that the prior experience of physical illness in childhood is associated with later experience of medically unexplained symptoms. METHOD: A nested case-control study was performed within a prospective birth cohort study: the Medical Research Council National Survey of Health and Development. The 5% most symptomatic individuals at age 36 years were identified and screened for physical illness. Subjects without defined physical diagnoses (N = 191) were compared with the remainder of the sample (N = 3,107) for childhood exposures. RESULTS: There was a powerful relationship between poor reported health of the parents when subjects were aged 15 years and symptoms at age 36; the relationship was independent of current psychiatric disorder. Medically unexplained symptoms were associated with abdominal pain in childhood but not with defined childhood diseases. CONCLUSIONS: Medically unexplained symptoms appear to be related to prior experience of illness in the family and previous unexplained symptoms in the individual. This may reflect a learned process whereby illness experience leads to symptom monitoring.

Quality of life in patients with multiple injuries--basic issues, assessment, and recommendations.

BACKGROUND: While the primary goal of trauma care continues to be the preservation of life, interest has begun to focus on disability and quality of life of those who survive. Numerous instruments have been developed to measure personal well-being, impairment, or subjective life-satisfaction. But there is no consensus regarding which instruments are most appropriate to use in multiply injured patients, and comparison of results are difficult. OBJECTIVE: The objective of this multinational conference was to arrive at a consensus regarding the measurement of quality of life in survivors of multiple trauma. Specifically we sought to identify the best time intervals for measurement and a minimum set of instruments. METHOD: The group reviewed instruments currently in use for quality of life measurement in multiply injured patients. A structured discussion covered the following topics: definition of the population, the concept of quality of life, the importance of different domains of quality of life at different time points, the type of measures and their validity, consistency, and practicability, the mode of administration, subject burden, and availability of population norms. RESULTS: The group suggested three time points, after 3, 12 and 24 months, for the assessment of quality of life after multiple injury. The Glasgow Outcome Scale (GOS) was suggested as an overall global outcome measure including death and vegetative state. The EuroQol was proposed to permit economic analysis, and the SF-36 as a validated global quality of life measure. CONCLUSION: While most selected measures are psychometrically sound, many have had limited use in the setting of multiple injuries. Researchers and clinicians may use these suggestions as a source of information when developing a measurement strategy.

Characteristics of patients presenting to a cardiac clinic with palpitation.

BACKGROUND: Palpitation is a very common presenting symptom in primary care and in cardiac clinics, associated with marked disability. Although serious arrhythmias are uncommon causes, treatment of persistent palpitation is difficult. AIM: To describe the cardiological, behavioural and psychological characteristics of consecutive patients presenting to a cardiac clinic with the main complaint of palpitation. DESIGN: Prospective evaluation of consecutive out-patients. METHODS: Participants were 184 consecutive patients with the complaint of palpitation referred to an out-patient cardiac clinic. Three assessments were used. Three to four weeks prior to clinic attendance, measures of symptoms, distress and disability were gathered, and a heart rate perception test was conducted. At the out-patient clinic, a routine clinical assessment was made. Three months later, patients received a questionnaire which included baseline measures of symptoms, distress and disability. RESULTS: Palpitation was associated with arrhythmias in 62 patients (34%), extrasystoles in 75 patients (41%) and awareness of sinus rhythm in 47 patients (26%). Distress and disability were common and persistent. There were significant differences in the characteristics of the three groups. DISCUSSION: Most patients presenting to secondary care with palpitation do not have serious underlying cardiovascular conditions. Concurrent psychological problems are common and persistent. Aetiology may be seen as an interaction of pathology, awareness of normal physiology, and psychological variables. Few patients require specialist cardiological treatment, but simple reassurance is of limited effectiveness. A stepped care approach may improve outcomes and needs rigorous evaluation.

Can clinical assessment of chest pain be made more therapeutic?

We describe the referral and management of consecutive patients attending a cardiac service with the presenting complaint of chest pain. Of 610 consecutive new referrals to five Oxford cardiac clinics over 12 weeks, 202 had chest pain as the presenting complaint: 91 (45%) angina, 101 (50%) non-cardiac chest pain, 8 (4%) both and 2 (1%) uncertain diagnosis. Information in clinic letters was sometimes ambiguous and contradictory and suggested a lack of precise information to patients. Patients with non-cardiac chest pain often had long histories, including considerable previous use of services and specialist investigations. There were delays in referral and assessment of patients. There are opportunities for simple changes in assessment procedures which might have substantial advantages for outcome and resource: (i) more detailed referral information from general practitioners, with an explicit statement of the reasons for referral; (ii) minor modifications to augment the assessment by provision of unambiguous information to patients and primary care at discharge.

Management of non-cardiac chest pain: from research to clinical practice.

BACKGROUND: Non-cardiac chest pain assessed by cardiologists in their outpatient clinics or by coronary angiography usually has a poor symptomatic functional and psychological outcome. Randomised trials have shown the effectiveness of specialist psychological treatment with those who have persistent symptoms, but such treatment is not always acceptable to patients and may not be feasible in routine clinical settings. OBJECTIVES: To describe a sample of patients referred to cardiac outpatient clinics from primary care in a single health district who were consecutively reassured by cardiologists that there was not a cardiac cause for their presenting symptom of chest pain. DESIGN: Systematic recording of referral and medical information of patients consecutively reassured by cardiologists. Reassessment in research clinic six weeks later (with a view to inclusion in a randomised trial of psychological treatment, which has been separately reported) and followed up at six months. SETTING: A cardiac clinic in a teaching hospital providing a district service to patients referred from primary care. PATIENTS: 133 patients from the Oxfordshire district presenting with chest pain and consecutively reassured that there was no cardiac cause during the recruitment period; 69 had normal coronary angiograms and 64 were reassured without angiography. INTERVENTION: A subgroup (n = 56) with persistent disabling chest pain at six weeks were invited to take part in a randomised controlled trial of cognitive behavioural treatment. MAIN OUTCOME MEASURES: Standardised interview and self report measures of chest pain, other physical symptoms, mood and anxiety, everyday activities, and beliefs about the cause of symptoms at six week assessment; repeat of self report measures at six months. RESULTS: Patients had a good outcome at six weeks, but most had persistent, clinically significant symptoms and distress. Some found the six week assessment and discussion useful. The psychological treatment was helpful to most of those recruited to the treatment trial, but a minority (15%) of those treated appeared to need more intensive and individual collaborative management. Patients reassured following angiography were compared with those reassured without invasive investigation. They had longer histories of chest pain, more often reported breathlessness on exertion, and were more likely to have previously been diagnosed as having angina, treated with antianginal medication, and admitted to hospital as emergencies. CONCLUSION: These findings suggest a need for "stepped" aftercare, with management tailored according to clinical need. This may range from simple reassurance and explanation in the cardiac clinic to more intensive individual psychological treatment of associated underlying and often enduring psychological problems. Simple ways in which the cardiologist might improve care to patients with non-cardiac chest pain are suggested, and the need for access to specialist psychological treatment discussed.

Psychological predictors of chronic posttraumatic stress disorder after motor vehicle accidents.

A prospective longitudinal study assessed 967 consecutive patients who attended an emergency clinic shortly after a motor vehicle accident, again at 3 months, and at 1 year. The prevalence of posttraumatic stress disorder (PTSD) was 23.1% at 3 months and 16.5% at 1 year. Chronic PTSD was related to some objective measures of trauma severity, perceived threat, and dissociation during the accident, to female gender, to previous emotional problems, and to litigation. Maintaining psychological factors, that is, negative interpretation of intrusions, rumination, thought suppression, and anger cognitions, enhanced the accuracy of the prediction. Negative interpretation of intrusions, persistent medical problems, and rumination at 3 months were the most important predictors of PTSD symptoms at 1 year. Rumination, anger cognitions, injury severity, and prior emotional problems identified cases of delayed onset.

What should British consultation-liaison psychiatry be doing?

Despite increasing clinical interest and research consultation-liaison (C-L) services in the United Kingdom are mainly haphazard and unsatisfactory. Although the clinical problems are similar to those in other Western countries, the answers must reflect the British health care system. The national C-L organization must formulate and promote detailed policies for 1) clinical priorities; 2) staffing and other resources; 3) integration with other specialist psychiatric services for local populations and primary care; and 4) persuading other medical organizations to place greater emphasis on psychological skills, training requirements, and practice. Some of our conclusions are parochial, some are generally applicable; others are applicable only to countries with comprehensive health care.

A British view of liaison psychiatry.

Although the general hospital patients' needs for the psychologic care are similar in Britain and the United States, the role, boundaries, and organization of liaison psychiatry are very different. These differences are examined and the British approaches described. Greater awareness of the nature of these differences and of clinical developments and research in the two countries would contribute to the further development of consultation and liaison.

Illness behavior and psychiatry.

The sociologic term illness behavior has been valuable in putting medical and psychiatric concept of illness in a broader perspective. The term is increasingly popular with psychiatrists, who use it in various ways, but particularly for patients who make considerable demands on their doctors. It has been seen as a symptom, a syndrome, or as a dimension. It is useful to see many patients, especially those seen within general hospitals, as suffering from "problems of illness behavior," but some other usages are idiosyncratic and unhelpful. We should avoid arbitrary statements about "abnormality" and ensure that the general term illness behavior is not used as a synonym for consultation behavior. Quantitative assessment requires multiple measures of particular aspects of illness behavior chosen for the particular purpose of the investigation.

Consultation-liaison psychiatry in western Europe. The European Consultation-Liaison Workgroup.

Consultation-liaison psychiatry (C-L) services have developed throughout Europe, largely as a result of individual local initiative. Reviews by contributors from 14 countries reveal similarities in national approaches and in the problems caused by inadequate resources, lack of recognition from psychiatric colleagues, and difficulties in integrating C-L with comprehensive systems of psychiatric care, which are mainly oriented toward community care. National C-L organizations and a recently established European Workgroup have focused attention on the clinical importance of C-L and the need to define national and local policies for its clinical role, staffing, and other resources. There is considerable and increasing interest in European C-L research.

Use of psychiatric services by patients referred to a consultation unit.

The psychiatric case registers for the hospital catchment area were examined to determine the use of psychiatric services over a 14-year period by a 4-year cohort of consecutive inpatient referrals to the consultation-liaison service of a British general hospital. Two-thirds of the subjects had no other psychiatric care during the survey period, but a third made considerable use of a wide range of specialist psychiatric services. Alcohol problems and dementia were notably associated with complex history of psychiatric management. Management of patients with repeated episodes of psychiatric care requires close collaboration with other services.

Significance of psychiatric symptoms in general medical patients with mood disorders.

Little difference was found between the psychiatric symptoms of medical patients and general-population subjects with affective disorder, both groups having been assessed with the same procedure (Present State Examination). Discrimination between medical patients with and without affective disorder was best achieved when patients with depressive and anxiety disorders were considered separately. Depressed mood, morning depression, and hopelessness were the key symptoms in the depressives, and nervous tension, free-floating anxiety, panic attacks, and specific phobias in the patients with anxiety disorders. Symptom profile did not distinguish patients with persistent affective disorders from those whose disorders had resolved at a 4-month follow-up.

Further evolution of a literature database: the international use of a common software structure and methodology for the establishment of national consultation/liaison databases.

Every day there are 6000-7000 papers published in science. Since the C-L psychiatrist may be asked to consult on a patient with any medical illness, and who may be on any medical drug, methods need to be developed to review the recent literature and have an awareness of current findings. At the same time, teachers need to develop a current listing of seminal papers for trainees and practitioners of this subspecialty of psychiatry. Experts chosen because of their writings and acknowledged contributions to their subspecialty interests have sifted through thousands of articles to select the ones they regard as the most important for trainees in C-L psychiatry. In addition, certain countries--Spain, Portugal, Germany, Mexico, Australia and Brazil are developing national databases of C-L literature not only for their own use, but also to bring them to the attention of other parts of the world. This fifth iteration of the C-L literature database has especially targeted the period of 1996-1999--the millennium issue--in order to have easier access to contemporary essential studies on common problems. Part II of this issue describes the seminal cardiac drug-psychotropic drug interactions that the C-L psychiatrist may encounter in the most common medical disease in the United States--coronary heart disease--with advise to the practitioner as to their management. The use of the Internet and institutional Intranets is described.

Consultation-Liaison psychiatric service delivery: results from a European study.

The reported findings of the European Consultation-Liaison Workgroup (ECLW) Collaborative Study describe consultation-liaison service delivery by 56 services from 11 European countries aggregated on a C-L service level. During the period of 1 year (1991), the participants applied a standardized, reliability tested method of patient data collection, and data were collected describing pertinent characteristics of the hospital, the C-L service, and the participating consultants. The consultation rate of 1% (median; 1.4% mean) underscores the discrepancy between epidemiology and the services delivered. The core function of C-L services in general hospitals is a quick, comprehensive emergency psychiatric function. Reasons to see patients were the following. deliberate self-harm (17%), substance abuse (7.2%), current psychiatric symptoms (38.6%), and unexplained physical complaints (18.6%) (all means). A significant number of patients are old and seriously ill. Mood disorders and organic mental disorders are most predominant (17.7%). Somatoform and dissociative disorders together constitute 7.5%. C-L services in European countries are mainly emergency psychiatric services and perform an important bridge function between primary, general health, and mental health care.

Prediction of emotional and social outcome after a heart attack.

Data from two prospectively studied series of patients recovering from heart attacks (n = 129 and 100) were analysed to determine the extent to which early findings can predict later psychological and social outcome. Some aspects of early and late outcome can be predicted with modest accuracy by multiple regression analysis of information obtained during the acute hospital admission. More accurate, and therefore clinically more useful, prediction of late outcome is possible in early convalescence. It is suggested that systematic clinical assessment during admission and a few weeks after return home could detect most patients in need of extra specialist rehabilitation.

Chest pain, palpitations and panic.

Chest pain and palpitations are commonly described in the general population and are frequent presenting symptoms in all medical settings. Although often transient, they can be persistent and are associated with considerable disability, distress, and concern about heart disease and use of medical resources. Both symptoms are associated with panic but also with other psychiatric disorders. It is most useful to consider etiology as multicausal and interactive; psychological factors affect interpretation of bodily perceptions and have deleterious effects on quality of life and use of medical resources. There is evidence that general measures and specific drug and psychological treatments can be effective. There is still uncertainty about the most appropriate ways of providing effective care to large numbers of patients.