Unrecognized physical illness prompting psychiatric admission.

BACKGROUND: We assessed factors that might contribute to clinicians erroneously attributing medically based changes in a patient's mental status to psychiatric illness. METHODS: Records of 1340 patients admitted to a VA hospital psychiatric unit and 613 to a public hospital psychiatric unit from 2001 to 2007 were reviewed. Cases admitted because of an unrecognized medical disorder underwent further analysis of the preadmission assessment and documented history of mental illness. RESULTS: Of 1340 patients whose records were reviewed, 55 (2.8%) had a medical disorder that caused their symptoms. Compared with patients admitted to medical units, patients inappropriately admitted to psychiatric units had lower rates of completion of medical histories, physical examinations, cognitive assessments, indicated laboratory and/or radiologic studies, and treatment of abnormal vital signs (P < .001 in each case). Among patients admitted to psychiatric units, 85.5% had a history of mental illness vs 30.9% of comparable admissions to medical units (Chi2(1) = 35.85; P < .001). CONCLUSIONS: Key assessment procedures are less likely to be performed in patients with mental status changes who are admitted to psychiatric units than in comparable patients admitted to medical units. Symptoms of patients with a history of mental illness are more likely to be attributed to psychiatric illness than are those of patients without such a history.

Inappropriate psychiatric admission of elderly patients with unrecognized delirium.

OBJECTIVES: To explore factors that might contribute to misattribution of mental status changes to psychiatric illness when an elderly patient actually has a delirium (mental status changes due to a medical condition). METHODS: Records of 900 elderly patients referred to a Veterans Affairs psychiatric inpatient unit and 413 to an inpatient psychiatric team at a public hospital from 2001 to 2007 were reviewed. Cases referred because of symptoms secondary to an unrecognized delirium underwent further analysis of preadmission assessments. Comparisons were made to elderly patients with delirium appropriately admitted to medical units. RESULTS: Thirty (2.3%) of the patients referred to psychiatric units were found to have a physical disorder requiring medical intervention within twelve hours. Compared to 30 delirious patients admitted to medical units, those inappropriately referred to psychiatric units had significantly lower rates of adequate medical histories, physical examinations, cognitive assessments, and laboratory/radiological studies. Among patients with delirium referred to psychiatric units, 66.7% had a history of mental illness, versus 26.7% of comparable admissions to medical units (chi (7) = 60.00, P < 0.001). CONCLUSIONS: Our findings suggest that elderly patients with delirium admitted to psychiatric units are less likely to undergo complete diagnostic assessments than delirious elderly patients admitted to medical units. Symptoms of delirium appear more likely to be incorrectly attributed to psychiatric illness in patients with a history of mental illness than in patients without such a history. Possible explanations for these findings and suggestions for addressing these issues are offered.

Nocebo effects with antidepressant clinical drug trial placebos.

We describe an individual who experienced unusual negative effects while taking a placebo during a clinical drug trial. A 26-year-old male took 29 inert capsules, believing he was overdosing on an antidepressant. Subsequently, he experienced hypotension requiring intravenous fluids to maintain an adequate blood pressure until the true nature of the capsules was revealed. The adverse symptoms then rapidly abated. The nocebo effect (undesirable symptoms following administration of an inert substance that the patient believes to be an active drug) may have significant negative impacts on certain patients. Further research is warranted to better understand this phenomenon.

Atypical neuroleptic malignant syndrome associated with olanzapine.

Neuroleptic malignant syndrome (NMS) is a potentially life-threatening adverse effect of antipsychotic agents. It generally is characterized by fever, altered mental status, rigidity, and autonomic dysfunction. A 53-year-old man developed NMS without rigidity while taking olanzapine. Such atypical cases may support either a spectrum concept of NMS or the theory that NMS secondary to atypical antipsychotics differs from that caused by conventional neuroleptics. More flexible diagnostic criteria than currently mandated by the the Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision, may be warranted.