Physicians at the medicine/psychiatric interface: what do internist/psychiatrists do?

Studies have convincingly demonstrated that some 50% of patients in primary care settings have both medical and psychiatric diagnoses requiring dual treatment. The concept of primary care psychiatry has emerged in recent years as one way to address this problem. In 1979 the first combined medicine-psychiatry residency was formed. There are now over 20 such programs, but there is little information on how these doubly trained physicians actually practice. In 1997, the authors surveyed the 268 physicians with board certification in both internal medicine and psychiatry that were listed with the American Board of Medical Specialties. Only 15% practiced any type of medicine at all; the rest were involved only in the practice of psychiatry. Although 75% identified themselves only as psychiatrists and worked predominantly in psychiatry, 95% reported using both their medical and psychiatric training in their professional work. They reported that the dual training made them better physicians, improved their professional credibility, and enhanced their diagnostic skills. Several significant barriers were discovered that directly affect the ability of physicians to practice in two fields. Findings, study limitations, and potential implications for the field and its patients are discussed.

Maintenance electroconvulsive therapy for chronic mentally ill patients: a case series.

OBJECTIVE: Maintenance electroconvulsive therapy (maintenance ECT) has emerged as an alternative treatment for patients who relapse repeatedly or cannot tolerate psychotropic medications. The pattern of maintenance ECT use in two university-affiliated hospitals was surveyed to evaluate its effectiveness in treating several disorders, establish treatment guidelines, and identify adverse side effects. METHODS: Records of 161 patients who received ECT from 1976 through 1988 were reviewed retrospectively. Nine patients who received maintenance ECT--prophylactic ECT treatments administered for longer than six months--were identified. The presence of target symptoms and behaviors in the periods before and after administration of maintenance ECT was compared. RESULTS: All nine patients experienced a complete or a significant partial remission of target symptoms. Six of the nine patients were ready for transfer to less restrictive settings. Given the small number of patients, treatment guidelines could not be established; however, patients with mood disorder required less frequent treatments than patients with thought disorder. Adverse effects were documented for two of the nine patients, but they were not severe enough to discontinue treatment. CONCLUSIONS: For this sample, maintenance ECT was a safe, efficacious, and well-tolerated treatment with minimal side effects. Further, controlled studies are warranted.

The amytal interview in the treatment of conversion disorder: three case reports.

The records of three consecutive patients who had a diagnosis of conversion disorder and received an amytal interview were reviewed. All diagnoses were made according to DSM-III-R criteria by a staff psychiatrist. Amytal was administered according to a previously published protocol. All patients were contacted 1 year following their hospital discharge. All patients tolerated the amytal interview without complications. The conversion symptoms in all patients remitted within several days of the interview and had not recurred at 1 year follow-up. In properly selected patients, the use of the amytal interview may be a safe, rapid, and efficacious intervention that can facilitate the resolution of conversion symptoms in the military setting.

Adjustment disorders in medically ill inpatients referred for consultation in a university hospital.

The study examined medical records of 121 medical-surgical inpatients diagnosed with adjustment disorder by psychiatric consultants in a university hospital. Medical illness was the primary stressor, evoking the maladaptive reaction in 83 (68.6%) cases. These patients were largely free of preceding psychiatric problems, suffering protracted hospitalizations for advanced illnesses, particularly malignancy and diabetes; in contrast, the 38 (31.4%) patients whose adjustment disorder was precipitated by a stressor other than medical illness had established psychiatric histories and recurrent problems with relationships or finances. The data suggest that in the medically ill, identifying the primary stressor producing an adjustment disorder is more instructive than focusing upon "predominant" symptomatology and "subtypes."