Lack of menstrual cycle effects on hypothalamic-pituitary-adrenal axis response to insulin-induced hypoglycaemia.

OBJECTIVE: Limited data are available on the effects of the menstrual cycle on the hypothalamic-pituitary-adrenal axis (HPA) function. This study evaluates HPA axis reactivity to insulin-induced hypoglycaemia over the menstrual cycle. PATIENTS: Twelve normal women were randomized to placebo and evaluated during three successive menstrual cycles. Menstrual phase was documented by menstrual diary and by oestradiol and progesterone levels at the time of each insulin tolerance test (ITT). Six normal men were included as a comparison in the statistical analysis. MEASUREMENTS: Afternoon ITTs were performed initially on the second or third day of menses in women, then seven more ITTs followed at one or two week intervals during the next 10 weeks. Serum measurements of glucose, adrenocorticotrophin (ACTH) and cortisol were obtained. RESULTS: The glucose and ACTH responses to the ITTs were similar between men and women. Cortisol levels at baseline and during the test were higher in men than in women, although the amount of change was similar. Glucose, ACTH and cortisol response to insulin-induced hypoglycaemia did not vary over the menstrual cycle or during repeat testing in men or women. CONCLUSIONS: These data show that it is unnecessary to control for menstrual cycle during insulin tolerance tests performed at 1600 hours. It is, however, necessary to control for the effect of sex on cortisol levels. Repeat testing more than one week apart does not appear to influence the glucose, ACTH or cortisol response to insulin stress.

Integrating medical and psychiatric treatment in an inpatient medical setting. The type IV program.

This study compares the treatment of patients with comorbid medical and psychiatric illness admitted to a high-acuity (Type IV) integrated medicine and psychiatry inpatient program with patients having psychiatric symptoms on general internal medicine wards (IMWs). More patients in the Type IV program had agitation, suicidal ideation, or psychosis as psychiatric admission behaviors when compared to IMW patients. Medical symptom improvement was comparable in the two settings, whereas, psychiatric symptoms improved more in the Type IV Program than on the IMWs despite more significant illness and comparable lengths of stay. Integrated care on the Type IV unit allowed shorter total lengths of stay for medical patients with serious psychiatric illness than would have occurred had the traditional sequential approach to care been used. The integrated Type IV medicine and psychiatry treatment program represents an efficient and effective process improvement in the way that medical patients with comorbid medical and psychiatric illness can be treated.

Fluvoxamine for somatoform disorders: an open trial.

Although the pharmacologic treatment of somatoform disorders has scarcely been investigated, there is reason to believe that antidepressants might be useful. We examined the response of 29 patients with somatoform disorders from a general medicine clinic to a selective serotonin reuptake inhibitor, fluvoxamine. The drug was administered in doses of up to 300 mg daily for 8 weeks. Sixty-one percent of the patients who took medication for at least 2 weeks were at least moderately improved. In addition to antidepressant effects, fluvoxamine had other beneficial effects and was well-tolerated. The benefits of drug therapy were modest but appear to warrant a placebo-controlled trial.

The classification of mental disorders in primary care: a guide through a difficult terrain.

BACKGROUND: Primary care physicians traditionally have a strong interest in the mental health of their patients. Three classification systems are available for them to diagnose, label, and classify mental disorders: 1) The ICD-10 approach with three options, 2) The DSM-IV approach with two options, and 3) the ICPC approach with two options. This article lists important similarities and differences between the systems to help potential users choose the option that best meets their needs. METHODS: Definitions for depressive disorder, anxiety disorder, and somatization disorder are compared on five characteristics of classification: 1. the domain, 2. the scope, 3. the nature of the definitions, 4. focus on episodes of care, and 5. clinical guidelines. RESULTS: Primary care physicians and psychiatrists have different perspectives, reflected in different classifications. Each system has specific possibilities and limitations with regard to the diagnosis of mental disorders. For common mental disorders it is possible, however, to choose codes from one system while maintaining compatibility with the other two. Comparability as to the diagnostic content of the different classes, however, is more difficult to establish. The available classification systems give both primary care physicians and psychiatrists options to diagnose, label, and to classify mental disorders from their own perspective, but once a system has been chosen the clinical comparability of a patient with the same diagnosis in other systems is limited. CONCLUSION: Compatibility among systems can be optimized by strictly following a number of rules. The conversion between ICPC and ICD-10 (and consequently DSM-IV) allows simultaneous use of ICPC and ICD-10 as a classification and DSM-IV as the standard nomenclature. This is of particular interest for computer based patient records in primary care. The clinical comparability of the same diagnosis in different systems however is limited by the characteristics of the different system.

Mental disorders and disability among patients in a primary care group practice.

OBJECTIVE: This article examines social and occupational disability associated with several DSM-IV mental disorders in a group of adult primary care outpatients. METHOD: The subjects were 1,001 primary care patients (aged 18-70 years) in a large health maintenance organization. Data on each patient's sociodemographic characteristics and functional disability, including scores on the Sheehan Disability Scale, were collected at the time of a medical visit. A structured diagnostic interview for current DSM-IV disorders was then completed by a mental health professional over the telephone within 4 days of the visit. RESULTS: The most prevalent disorders were phobias (7.7%), major depressive disorder (7.3%), alcohol use disorders (5.2%), generalized anxiety disorder (3.7%), and panic disorder (3.0%). A total of 8.3% of the patients met the criteria for more than one mental disorder. The proportion of patients with co-occurring mental disorders varied by index disorder from 50.0% (alcohol use disorder) to 89.2% (generalized anxiety disorder). Compared with patients who had a single mental disorder, patients with co-occurring disorders reported significantly more disability in social and occupational functioning. After adjustment for other mental disorders and demographic and general health factors, compared with patients with no mental disorder, only patients with major depressive disorder, bipolar disorder, phobias, and substance use disorders had significantly increased disability, as measured by the Sheehan Disability Scale. CONCLUSIONS: Primary care patients with more than one mental disorder are common and highly disabled. Individual mental disorders have distinct patterns of psychiatric comorbidity and disability.

False positive results: a challenge for psychiatric screening in primary care.

OBJECTIVE: The goal of this study was to characterize primary care patients with false positive results on screens for mental disorders. METHOD: A sample of 1,001 primary care patients completed self-administered screens and structured interviews for DSM-IV diagnoses. RESULTS: A substantial proportion of the patients with false positive screen results for at least one diagnosis met the diagnostic criteria for other psychiatric disorders. They also had significantly greater functional impairment and higher rates of recent use of mental health services than the subjects with true negative results on the screens. CONCLUSIONS: Although the positive predictive values of screens for specific mental disorders are in line with those of other medical screens, false positive results are not uncommon. This may be due in part to the sensitivity of brief screening instruments to nonspecific symptoms. The results suggest that as with other screens used in primary care, patients with false positive results on screens for mental disorders should receive clinical attention.

Medical training in psychiatry residency. A proposed curriculum.

During the coming decades, psychiatrists will be asked to participate to a greater extent in the physical evaluation and treatment of patients with behavioral or emotional problems. Despite the high frequency with which psychiatric symptoms are caused or exacerbated by organic disease, psychiatrists have been reluctant, and in some ways, even discouraged to include physical assessments. Psychoanalysis and concerns about boundary issues have influenced psychiatrists to cede physical assessment and physical illness to other physicians. To help overcome these barriers to improved care of psychiatric patients, a curriculum is proposed for psychiatry residents. It will allow them to better use their medical backgrounds while increasing their contributions as mental health specialists.

A family study of hypochondriasis.

To examine the diagnostic validity of hypochondriasis, we undertook a preliminary family study. Nineteen probands with and 24 without DSM-III-R hypochondriasis were identified among outpatients attending a general medicine clinic. Seventy-two first-degree relatives of hypochondriasis probands and 97 relatives of control probands were personally interviewed with the use of the Structured Clinical Interview for DSM-IV. These relatives also completed self-administered measures of hypochondriasis, psychological and somatic symptoms, and personality traits. No increase in the rate of hypochondriasis was found among the relatives of hypochondriasis probands compared with the relatives of control probands. With respect to other mental disorders, only somatization disorder was more frequent among the hypochondriacal relatives. These relatives also scored higher on measures of hostility, antagonism, and dissatisfaction with medical care. The findings of this study suggest that hypochondriasis may not be an independent disorder but a variable feature of other psychopathology, one that may include somatization disorder.

Reassurance therapy: what to say to symptomatic patients with benign or non-existent medical disease.

Reassurance is one of the most important therapies that primary care physicians give; however, little has been written about it in the literature. This article suggests six steps needed for effective reassurance in patients with benign disease or symptoms not explained by disease. These include; 1) question and examine the patient, 2) assure the patient that serious illness is not present, 3) suggest the symptom will resolve, 4) tell the patient to return to normal activity, 5) consider non-specific treatment, and 6) follow the patient Only if these systematic steps are followed will reassurance consistently work. Since examination of the patient is a critical component of reassurance therapy, it can most effectively be administered by individuals who include a physical assessment as a part of the clinical evaluation.

Let's train psychiatric residents to use their medical skills to meet twenty-first century demands.

The health care system is moving toward the integration of medical and psychiatric services since through this mechanism more efficient care can be provided to the many high-cost and complicated patients with psychiatric comorbidity in the primary care setting. In order for psychiatry to respond to the demands resulting from these projected changes, adjustments in psychiatric residency curricula will be required. This article suggests curricular revisions that increase training in psychiatric diagnosis and treatment in outpatient and acute care medical settings, emphasize development of psychiatric skills appropriate to individuals with a medical background, and improve the ability of psychiatrists to coordinate mental health care in primary care settings.

Psychiatric training in medicine residencies: current needs, practices, and satisfaction.

The purpose of this study was to determine the current level of psychiatric training in internal medicine residencies, satisfaction with this training, and perceived need, if any, for more training. Surveys were mailed to all training directors of accredited primary care (N = 178) and categorical (N = 410) internal medicine residencies in the United States; 110 primary care (62%) and 238 categorical (58%) training directors returned the surveys. Seventy-five percent of categorical and 66% of primary care training directors thought their program should spend more time on psychiatric disorders. For all categories of psychiatric disorder, training intensity was greater and satisfaction with training higher in the primary care programs, but less than half of the directors were satisfied with their current level of training, e.g., 33% of categorical and 47% of primary care directors were satisfied with their residents training concerning depression. Training in somatoform disorders, psychotropic drugs, and office psychotherapy were most frequently identified as deficient. The most favored additions to the curriculum were psychiatric consultants in medical clinics and on medical wards. Although most outpatient care for psychiatric disorders is given by primary care physicians, internal medicine training directors perceive current levels of training in their residencies as inadequate. Innovative collaborations between medicine and psychiatry departments will be necessary if treatment of psychiatric disorders in primary care is to be improved.

Physician recognition of hypochondriacal patients.

To examine primary care physician recognition of hypochondriacal patients, we identified a series of such patients in a general medicine clinic using the Whiteley Index. Clinic physicians made blind global ratings of severity of physical disease and unreasonable fear of illness (hypochondriasis) and completed a checklist of somatizing characteristics. Patient records were audited for diagnoses, laboratory tests, consultations, and medications prescribed. Twenty-nine (14%) of 210 patients scored above an established cutoff on the Whiteley Index. These hypochondriacal patients were rated by clinic physicians as more hypochondriacal and were more often given psychiatric diagnoses. Also, clinic physicians identified more somatizing features among hypochondriacal patients including their own reaction to them. This recognition of hypochondriac characteristics may have contributed to better management but may need to be raised to the diagnostic level for maximum benefit.

Somatization. Diagnosis and management.

Somatization, the somatic expression of psychological distress, occurs in a large proportion of primary care patients. It is associated with substantial distress and impairment and with increased health care utilization. Some somatizing patients have a history of multiple unexplained complaints (somatization disorder), others are excessively worried about serious illness (hypochondriasis), and still others have psychiatric disorders that present with somatic symptoms (depression and anxiety). In general, somatizing patients are characterized by abnormal illness behavior (eg, failure to respond to treatment, excessive utilization of care) and psychological distress (eg, depressive symptoms, psychosocial stressors). Recognition requires alertness to characteristic features and skillful interview technique. Successful management begins by legitimizing symptoms. Restraint should be used in performing workups and assigning diagnoses to somatizing patients. Treatment goals should be clarified and regular visits scheduled. Also, behaviors that threaten the physician-patient relationship should be dealt with. Depression and anxiety should be treated when present. Pharmacologic and psychological treatments for somatizing patients have been described, although none has proven efficacy.

Relationship of 24-hour urinary free cortisol to 4-hour salivary morning and afternoon cortisol and cortisone as measured by a time-integrated oral diffusion sink.

The relationship between salivary corticosteroids integrated over 4-hour periods and urinary free cortisol collected over 24 hours was investigated in normal controls. Twenty-one normal volunteers wore "oral diffusion sink" sampling devices in their mouths for two 4-hour periods (08:00-12:00 hours and 13:00-17:00 hours) and on the same day collected a 24-hour urine specimen. Time-integrated salivary corticosteroid concentrations were determined from the sample devices and urinary free cortisol was measured. Salivary corticosteroids were not consistently higher in the morning than in the afternoon period and did not differ between men and women. Urinary free cortisol levels were higher in women. No salivary corticosteroids measure was significantly correlated with urinary free cortisol. We conclude that time-integrated salivary corticosteroids do not reflect urinary free cortisol levels in normal controls.

CRH challenge test in anxious depression.

Recently, renewed interest has developed in the concept of anxious depression. Using an operational definition of "anxious depression" based on the SADS interview, 25 patients with major depressive disorder were separated into anxious (n = 14) and nonanxious (n = 11) subtypes. These two patient groups and normal control subjects received an intravenous corticotropin-releasing hormone challenge test. Adrenocorticotropic hormone (ACTH) and cortisol responses were compared among the three groups. Patients with anxious depression had significant attenuation of ACTH response when compared to nonanxious patients and normal control subjects.

DSM-IV field trial: testing a new proposal for somatization disorder.

OBJECTIVE: The purpose of this study was to evaluate for APA a proposed strategy to diagnose somatization disorder for possible inclusion in DSM-IV. METHOD: Five sites--Washington University, University of Kansas, University of Iowa, University of Arkansas, and Mount Sinai Medical Center in New York--participated in a collaborative field trial. Female subjects (N = 353) were recruited from several different services (psychiatry, internal medicine, and family practice) and were evaluated for the presence or absence of the disorder. This assessment was performed with a new instrument constructed by combining all the criteria for somatization disorder from the proposed criteria for DSM-IV, DSM-III, DSM-III-R, Perley-Guze, and proposed criteria for ICD-10. RESULTS: A high level of concordance was found between the proposed diagnostic strategy for DSM-IV and the current criteria (DSM-III-R), as well as the earlier criteria (Perley-Guze and DSM-III). The ICD-10 criteria agreed poorly with all other criteria sets. The level of experience of the rater (expert versus novice) with the earlier (Perley-Guze, DSM-III) and current (DSM-III-R) criteria did not influence the identification of cases by use of DSM-IV criteria. No racial effect was introduced by any of the criteria sets. CONCLUSIONS: The strategy for DSM-IV is an accurate and simpler method of diagnosing somatization disorder that does not require special expertise for proper use.

One-year follow-up of medical outpatients with hypochondriasis.

To examine the diagnostic stability and outcome of hypochondriasis, the authors followed 50 patients with this disorder and 50 age- and sex-matched control subjects after 1 year. After 1 year, two-thirds of the subjects continued to meet criteria for hypochondriasis, and the remaining third had persisting hypochondriacal symptoms. The hypochondriacal subjects were improved on most measures but still differed from the control subjects with regard to attitudes, perceptions, and behaviors that had distinguished them initially. More severe symptoms, longer duration of illness, and coexisting psychiatric illness were predictive of a worse outcome. The data indicate that the diagnosis of hypochondriasis is stable over time, and that, although symptoms wax and wane, characteristic features persist. The findings underscore the importance of diagnosing and treating hypochondriasis in medical outpatients.

Psychiatric comorbidity among patients with hypochondriasis.

The purpose of this study was to determine the nature and extent of comorbidity among patients with DSM-III-R hypochondriasis and to examine the relationships between this disorder and coexisting psychiatric illness. For this purpose, patients seen in a general medicine clinic were screened using measures of hypochondriacal attitudes and somatic symptoms. Those scoring above an established cutoff were given a structured diagnostic interview. In this manner, 50 patients who met DSM-III-R criteria for hypochondriasis and 50 age- and sex-matched controls were identified. The presence of other psychiatric disorders (current and past) was determined by means of the same diagnostic interview. More hypochondriacal subjects (62.0%) had lifetime comorbidity than did controls (30.0%). Major depression, the most frequent comorbid disturbance, was usually current and most often had an onset after that of hypochondriasis. Panic disorder with agoraphobia, the most frequent anxiety disorder, was also current but often began before or at the same time as hypochondriasis. Few subjects met criteria for somatization disorder but a third qualified for a subsyndromal form of this disorder. The data show that, in medical outpatients with hypochondriasis, mood and anxiety disorders frequently coexist. This comorbidity is subject to varying interpretations including overlap of symptom criteria, treatment-seeking bias, and the possibility that hypochondriasis predisposes to or causes the comorbid disorder, as seems likely in the case of depression. In some instances hypochondriasis may be an associated feature of another illness.