Collaboration between the Air Force, VA, and a university psychiatry department on an inpatient unit.

The David Grant Medical Center at Travis Air Force Base in California is the site of a collaboration between the U.S. Air Force, the Department of Veterans Affairs, and the School of Medicine of the University of California, Davis, which was begun in 1994 to assure optimum use of resources and provide broader educational experiences to residents and students. The three systems have been integrated most fully on an inpatient mental health unit. The authors describe the history and development of the collaboration, focusing on how the model has helped the three organizations address clinical, institutional, and educational needs.

Objectives to direct the training of emergency medicine residents on off-service rotations: psychiatry.

Objectives for Emergency Medicine residents on a Psychiatry rotation is the 33rd article in this continuing series of off-service objectives. Psychiatric presentations, including substance abuse and violent behavior, are ubiquitous in the emergency department. In addition, psychological issues influence every aspect of clinical care. A psychiatry rotation can be valuable in emergency medicine training. This experience can be enhanced by clearly defined learning objectives in clinical psychiatry.

Three cases of adult attention-deficit hyperactivity disorder.

Three cases of adult patients with attention-deficit hyperactivity disorder who received their initial clinical evaluation and management in an Air Force Mental Health Clinic are presented. Diagnostic, therapeutic, and administrative issues pertinent to these patients are discussed. Clinicians should be alert to the diagnostic possibility of attention-deficit hyperactivity disorder in adult patients reporting the characteristic history and symptoms.

Review of clinical use of sertraline by family practice physicians in a small Air Force hospital.

The clinical use of sertraline for 1 year in a family practice clinic in a small Air Force hospital was reviewed. Retrospective chart review showed that 85% of patients receiving five or more prescriptions for sertraline had a diagnosis of depression; the remainder were treated for chronic pain or dysthymia. The patients in the review needed dose increases (above the recommended starting dose of 50 mg qd) in nearly 50% of the cases. Clinicians using sertraline for the treatment of affective illness in the primary care setting should be aware of the likelihood for dose increases to achieve maximal clinical benefit.

Psychiatric profiles in the U.S. Air Force: a clinical interpretation of Air Force Instruction 48-123.

The foundations of our current system for profiling military psychiatric patients were laid during World War II, well before the development of the first version of the Diagnostic and Statistical Manual of Mental Disorders. The general principles and terminology remain in use today through Air Force Instruction 48-123, Medical Examination and Standards. The terminology used is clearly outdated, making it difficult to use and risking misuse, deploying the wrong person or denying deployment to an appropriate person. Our objective is to review the current standards for making psychiatric profiles in the U.S. Air Force and propose a practical interpretation of the current Air Force Instruction. Considerable research remains to be done to improve our profile system, especially in light of the development of effective treatments for many psychiatric illnesses. Although prognostic data are available for some illnesses, little research has been done on military populations and essentially none of it considers the rigors of military deployment. Diagnosis, prognosis, duty environments, and demands of duties all must be considered in making profile decisions. Reductionistic approaches more simple than this will serve neither the commander nor the airman.

Denial of pregnancy: a case study and literature review.

A case is presented of a young active duty woman who experienced nonpsychotic denial of pregnancy until she precipitously delivered a healthy full-term infant. Despite the lack of prenatal care and the requirement for neonatal resuscitation, the child has apparently developed normally. The woman had no ongoing psychiatric illness. She was able to make appropriate use of medical, nursing, and social work resources to function well with her child at home. The recent literature on denial of pregnancy is reviewed, and the clinical differences between nonpsychotic and psychotic denial of pregnancy are described. Clinical management and mobilization of social support structures can improve the chances of successful clinical outcomes in nonpsychotic denial of pregnancy.

Psychotic disorder associated with isoniazid.

We evaluated a patient who developed a psychotic disorder after 4 months of isoniazid prophylaxis for a positive tuberculosis tine test. His symptoms resolved within 2 weeks of discontinuing the isoniazid. Clinicians should be aware of the possibility of psychotic symptoms with the use of this agent.

Comorbid affective disorders and personality traits in alcohol abuse inpatients at an Air Force Medical Center.

A retrospective chart review of 2 years of admissions (1995-1996) for alcohol abuse and alcohol dependence patients on an inpatient substance abuse unit showed the prevalence of comorbid affective disorders, personality disorders/subsyndromal personality traits, and the combination of all three diagnoses to be 8.2, 17.5, and 9.6%, respectively. The available literature on these additional diagnoses in substance abusers is reviewed and compared with the findings of the current study. Patients identified for inpatient substance abuse treatment need full psychiatric evaluation for other Axis I and Axis II comorbidity that may greatly affect their treatment plans and clinical prognoses.

An examination of narcissistic personality traits as seen in a military population.

Various studies examining the prevalence of personality disorders in civilian inpatient and outpatient populations have consistently found narcissistic personality disorder to be one of the least common. In striking contrast to this, a recently published study showed narcissistic personality features to be among the most common personality features in a military outpatient clinic population. This paper examines several possible explanations for this finding. This surprisingly high relative incidence of narcissistic personality features may be related to a self-selection bias on the part of persons choosing a military career. Narcissistic personality traits may confer adaptive advantage in certain military professional roles. Kohut's theory of specific transference requirements in individuals with narcissistic character structure serves as a useful explanatory model for these findings.

Psychiatric treatment and operational readiness: clinical guidelines for Air Force practice.

Clinical criteria for psychiatric illnesses that are career limiting to active duty Air Force personnel are defined in Air Force Instruction (AFI) 48-123. The terms used in the AFI are not sufficiently specific to the standards of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The authors review AFI 48-123 for conditions commonly seen in Air Force mental health practice and offer clinical interpretation of this AFI to bring it into line with DSM-IV. As a result of this synthesis, decisions regarding which mental health conditions warrant medical evaluation board disposition are clearer and more uniform. Clinicians and administrators are encouraged to refer to this paper for assistance in making decisions on mental health patients.

Ocular side effects of lithium--a review.

Lithium salts are commonly prescribed psychiatric medications. While they are usually safely used on outpatients, lithium preparations are associated with systemic and ocular side effects with both acute and chronic use. The optometrist should be aware of the ocular side effects so as to participate in the management of these patients. Ocular side effects may be the first signs of lithium toxicity.

Depression and topical ophthalmic beta adrenergic blockade.

Beta adrenergic blocking agents are in widespread use as both systemic and topical medications. While they are safely used in the great majority of cases, several side effects are well known. Central nervous system side effects, specifically depression, can be among the most clinically important of these and must be investigated by the clinician.

Internal carotid artery disease.

Internal carotid artery disease is a challenge to the optometrist because of its full spectrum of manifestations. A detailed case history and a thorough evaluation of the ocular and visual signs and symptoms are invaluable in the appropriate management of the patient. The optometric practitioner must consider this disease in middle-aged or elderly patients who present with suggestive signs and/or symptoms. Appropriate diagnosis and management of the disease will, it is hoped, result in the continued visual health and longevity of these patients.