The decline of state mental hospitals as training sites for psychiatric residents.

There has been national concern regarding the decreasing number of U.S. medical students entering psychiatric residency training programs in the 1970s at the same time that the Graduate Medical Education National Advisory Committee (GMENAC) report designated psychiatry as one of only three medical specialties with a manpower shortage. The authors document the decline in psychiatric residents in state mental hospitals from 1975 to 1980 and analyze five possible explanations for this absolute and relative decrease. They discuss approaches to altering the situation as well as the emerging role of the state mental hospital in the future training of psychiatric residents.

Drug promotion and labeling in developing countries: an update.

Recent studies of drug promotion and labeling in Third World countries since 1972 have observed important changes in the policies of multinational corporations. Earlier studies found that multinational and national drug companies often grossly exaggerated the indications for the drugs and minimized or ignored the hazards. In the latest study, initiated in 1987, considerable improvement in promotional practices of the multinational corporations has been found, but little or no improvement on the part of the national companies. As a result, physicians are still provided with grossly exaggerated claims and the hazards of prescription drugs are covered up or glossed over. A very serious problem--the marketing of fraudulent drug products--has been identified in a number of Third World countries. Drug products are shaped and colored to resemble the original multinational company product, but contain only a small percentage of the active ingredient stated on the label, or perhaps none at all. In Indonesia fraudulent drug products may represent 20-30% of all drug products in the market. Similar fraudulent products have been reported in Brazil, Thailand, Bangladesh and Malaysia.

Allogeneic peripheral blood stem cell transplant for myelodysplasia after chemotherapy for post-transplant lymphoma in a cardiac transplant recipient at 10 years.

A 32-year-old male received an allogeneic peripheral blood stem cell transplant (alloPBSCT) for myelodysplasia from his one HLA-A antigen mismatched brother. He is alive with trilineage engraftment and without active GVHD 200 days after transplant. In July 1986 he underwent orthotopic cardiac transplantation for viral cardiomyopathy and has received continuous immunosuppressive therapy. A post-transplant lymphoproliferative disorder with Hodgkin-like histopathology was diagnosed in August 1993 and was successfully treated with four cycles of MOPP chemotherapy. Due to persistent pancytopenia he underwent a bone marrow aspiration and biopsy in May 1996 which revealed monosomy 7 and morphologic changes compatible with myelodysplasia. This is the first report of a cardiac transplant recipient receiving an allogeneic hematopoietic stem cell transplant.

Patients' awareness of extrapyramidal reactions to neuroleptic drugs: possible evidence for the role of catecholamines in perception.

The awareness of extrapyramidal reactions during initiation of neuroleptic treatment was studied in 14 patients. Only one patient spontaneously identified the presence of dystonia. The other 13, including 3 who had experienced extrapyramidal reactions during previous hospitalizations, did not fully identify the presence of symptoms, although several had vague discomfort. There was marked variability in acknowledgement of symptoms in response to prompting by staff members. The findings are similar to reports of agnosia for hemiparesis after parietal lobe injury and also to descriptions of agnosia in animals caused by destruction of dopaminergic neurons. Since extrapyramidal reactions represent blockade of dopaminergic neurotransmission, patients' inability to perceive the reactions may represent evidence for catecholaminergic modulation of sensory perception.

Self-reported stress: findings from the 1985 National Health Interview Survey.

The National Health Interview Survey's 1985 Health Promotion and Disease Prevention Questionnaire included questions on the amount of stress experienced in the past 2 weeks, the effect of stress on health, thoughts about seeking help for personal or emotional problems, and actual help-seeking behaviors. This report examines responses to these questions and analyzes self-reported levels of stress by sex and other respondent characteristics. In 1985, an estimated 34 million people aged 18 years and older experienced "a lot" of stress in the 2-week period preceding the interview. Women were more likely than men to report a lot of stress (23 percent versus 18 percent), and respondents 65 years of age or older were more likely than younger respondents to report "almost no" stress. An estimated 21 million people (13 percent) believed that, over the past year, stress had "a lot" of effect on their health. Seventeen percent of the population considered seeking help in the past year for personal or emotional problems from family, friends, helping professionals, or self-help groups. Sixty-nine percent of those who thought about seeking help reported that they actually did seek help. In terms of health practices, men and women who reported higher levels of stress than others of their sex also were more likely to report that they rarely or never ate breakfast, slept 6 or fewer hours per night, were physically less active than their peers, or drank more alcoholic beverages than usual in the 2 weeks prior to the survey.

The Cuban immigration of 1980: a special mental health challenge.

The 124,769 Cubans who entered the United States from Cuba in a boatlift in 1980 included a small minority of people who needed mental health care. Some had been taken involuntarily from psychiatric hospitals, mental retardation facilities, jails, and prisons. The National Institute of Mental Health, Public Health Service (PHS), was responsible for mental health screening, evaluation, and treatment of the Cuban Entrants. Bilingual psychiatrists and psychologists found that many Entrants given preliminary evaluations showed evidence of transient situational stress reactions, not psychiatric illnesses. Entrants who had not yet been sponsored were consolidated into one facility in October 1980, and about 100 of those with severe problems were transferred to an Immigration and Naturalization Service-PHS evaluation facility in Washington, DC. Between March 1, 1981, and March 1, 1982, a total of 3,035 Entrants were evaluated at both facilities. Among the 1,307 persons who presented symptoms, there was a primary diagnosis of personality disorders for 26 percent, schizophrenic disorders for 15 percent, adjustment disorders for 14.5 percent, mental retardation for 8.6 percent, chronic alcohol abuse for 8.6 percent, and major depression for 7.2 percent. Only 459 Cubans with symptoms were found to be in need of further psychiatric care. As of October 1984, many Entrants with psychiatric illnesses remained under inpatient or community-based halfway house psychiatric care as a direct Federal responsibility. A PHS program for further placement in community-based facilities is underway.

Control of stress and violent behavior: mid-course review of the 1990 health objectives.

Control of stress and violent behavior is 1 of the 15 priority areas addressed in the 1990 health objectives for the nation. For control of stress, improved awareness of appropriate community service agencies and increased scientific knowledge of stress effects are the main objectives. For control of violent behavior, the objectives focus on three major problems: (a) deaths from homicide among young black males, (b) adolescent suicide, and (c) child abuse. Since the last progress report, published in 1984, more than 200 research projects directly related to these objectives have been funded, and a variety of implementation actions have been undertaken. During this period, baseline data on such critical concerns as homicides among blacks and Hispanics, suicide, family violence, and perceived stress have been obtained, thereby encouraging further study and facilitating achievement of the objectives. The mid-decade status report and recommendations that are presented in this article were initiated in a September 1985 review, by the Acting Assistant Secretary for Health, of progress toward achieving the 10 stress and violent behavior objectives selected for Federal implementation by the year 1990. The most recent available data have been used to update information on these 10 priority objectives.

Campus student suicide rates: fact or artifact?

A review of all English-language studies (14 foreign and 17 American) on campus student suicides was undertaken. Only studies reporting original data and containing sufficient demographic information to compute standard mortality rates (SMR) or crude suicide rates were analyzed and organized into single-site studies. Only 4 single-site studies had a higher suicide rate than the comparable populations. Multiple-site collaborative studies done in the United States since 1960 strongly suggest a campus student suicide rate significantly less than in the matched control population. However, deficiencies in case finding, case definition, sampling bias, and statistical techniques may place these conclusions in doubt. The author outlines research methods that might be applied to future multiple-site studies to resolve questions related to late adolescent and young adult suicidal behavior on campus and in other similar educational settings.

The prevention of suicidal behaviors: an overview.

The authors discuss the development of the concept of prevention as it has evolved from the public health and mental health fields. Concepts of epidemiology, treatment, and community mental health are defined in terms of their contributions to the evolution of prevention thinking. Four models of prevention are presented and critiqued: the public health model, the operational model, the antecedent conditions model, and the injury control model. Essential ingredients for implementing effective preventive interventions are presented, as well as examples of practical preventive interventions.

The place of suicide prevention in the spectrum of intervention: definitions of critical terms and constructs.

The authors trace the evolution of prevention models and conceptual foundations for the prevention of disorders starting with the public health/medical model and concluding with the contemporary model recently proposed by the Institute of Medicine of the National Academy of Sciences. They compare and contrast the contributions of each model toward the theoretical reduction of suicide in the general population. Risk and protective factors as they relate to suicidal behaviors are identified. The paper explores conceptual frameworks used to understand population-level risk factors and moves toward a discussion of how to target individuals at risk for suicidal behaviors. First-order and second-order targets of change in prevention efforts are defined and examples provided.

Suicide prevention programs: issues of design, implementation, feasibility, and developmental appropriateness.

Emerging models of prevention focus on population-level risk reduction through enumerating antecedent conditions that are linked to subsequent expressions of disorder and dysfunction. The authors discuss the essential ingredients for successful prevention programs--comprehensiveness, fidelity, and intensity. The authors describe how to mount prevention programs to increase feasibility, access, and effectiveness. Suicide is an epidemic of low frequency in the general population and therefore does not receive appropriate attention in public health prevention campaigns. They argue for nesting suicide prevention programs within existing public health preventive intervention programs and provide some examples of how to reduce vulnerabilities and risk conditions for subsequent suicidal behaviors.

Inpatient standards of care and the suicidal patient. Part II: An integration with clinical risk management.

The authors elaborate on the standards of care for the assessment, management, and treatment of hospitalized suicidal patients. The authors attempt to synthesize the concepts of the minimal standard of care with clinical risk management and clinical judgment. They point out the areas of overlap and where optimum care diverges from legal standards of care. Case examples are provided to illustrate major areas of concern. Alleged failures of omission and commission are discussed. Tables are provided that differentiate duties and responsibilities between and among clinicians, hospital staff, and hospital administration.

The Big Ten Student Suicide Study: a 10-year study of suicides on midwestern university campuses.

The Big Ten Student Suicide Study was undertaken from 1980-1990 to determine the suicide rates on Big Ten University campuses. The study design attempted to address many of the statistical and epidemiological flaws identified in previous studies of campus student suicides. The 10-year study collected demographic and correlational data on 261 suicides of registered students at 12 midwestern campuses. The largest number of suicides for both males and females were in the 20-24-year-old age group (46%), and amongst graduate students (32%). The overall student suicide rate of 7.5/100,000 is one half of the computed national suicide rate (15.0/100,000) for a matched sample by age, gender, and race. Despite the overall lower suicide rate, the analyses revealed that students 25 and over have a significantly higher risk than younger students. Although women have rates roughly half those of men throughout their undergraduate years, graduate women have rates not significantly different from their male counterparts (graduate women 9.1/100,000 and graduate men 11.6/100,000).

Inpatient standards of care and the suicidal patient. Part I: General clinical formulations and legal considerations.

The most common legal action involving psychiatric care is the failure to reasonably protect patients from harming themselves. In this regard it is critical to understand that courts have tended to impose much stricter standards on inpatient than on outpatient care; that at the present time, most malpractice actions involve clinical activities related to inpatient care (negligent admission, treatment, supervision, discharge, etc.). This article reviews the current climate in the legal and clinical formulation of standards of care for hospitalized adult suicidal patients. It suggests general guidelines for effective assessment, management, and treatment procedures that balance the need for high-quality care by a reasonable and prudent practitioner with the requirements of court-determined and statutory standards. The authors specifically discuss court cases that show common failure situations in inpatient care, discharge planning, and follow-up (e.g., problems in pharmacotherapy, the decision to hospitalize, the assessment of imminence and lethality, etc.). The paper also emphasizes the crucial element of clinical judgment in developing any inpatient standard of care.

Beyond the Tower of Babel: a nomenclature for suicidology.

Suicidology finds itself confused and stagnated for lack of a standard nomenclature. This paper proposes a nomenclature for suicide-related behavior in the hope of improving the clarity and precision of communications, advancing suicidological research and knowledge, and improving the efficacy of clinical interventions.

Children of psychiatrically ill parents: a prevention perspective.

A number of risk factors have been associated with the etiology and pathogenesis of psychiatric disorders in children of psychiatrically ill parents. The author reviews the evidence for genetic transmission of psychopathology in families, particularly depression, schizophrenia, and alcoholism. Genetic factors appear to play less of a role in transmission than the characteristics of the child and the environmental consequences of the parent's illness. Some risk factors, such as ineffective parenting, poor communication patterns, and chaotic environments, may be modified by preventive interventions. Such interventions can improve family stability, foster the parents' ability to meet the child's needs, and minimize the pathology to which the child is exposed. Broad-based preventive interventions for the general population are also discussed.