Constant observation in the general hospital.

Constant observation (CO) is a technique in which continuous one-to-one monitoring is used to assure the safety and well-being of an individual patient or others. This study reviewed 115 patient charts in a tertiary-care hospital to determine the correlates and predictors of the financial cost of CO. The mean duration for CO was 13.9 days with a median of 7.5 days. The cost average was $3,415 per incident with a range of $144-$68,500. The median cost was $1,872. The most common diagnosis was organic mental syndrome. Significant predictors of CO were disorientation, psychiatric medication used, and absence of alcohol use.

Adjustment disorder: a multisite study of its utilization and interventions in the consultation-liaison psychiatry setting.

The consultation-liaison (C-L) psychiatry services of seven university teaching hospitals in the United States, Canada, and Australia (the MICRO-CARES Consortium) used a common clinical database to examine 1039 consecutive referrals. A diagnosis of adjustment disorder (AD) was made in 125 patients (12.0%); as the sole diagnosis, in 81 (7.8%); and comorbidly with other Axis I and II diagnoses in 44 (4.2%). It had been considered as a rule-out diagnosis in a further 110 (10.6%). AD with depressed mood, anxious mood, or mixed emotions were the commonest subcategories used. AD was diagnosed comorbidly most frequently with personality disorder and organic mental disorder. Sixty-seven patients (6.4%) were assigned a V code diagnosis only. Patients with AD were referred significantly more often for problems of anxiety, coping, and depression; had less past psychiatric illness; and were rated as functioning better--all consistent with the construct of AD as a maladaptation to a psychosocial stressor. Interventions were similar to those for other Axis I and II diagnoses, in particular, the prescription of antidepressants. Patients with AD required a similar amount of clinical time and resident supervision. It is concluded that AD is an important and time-consuming diagnostic category in C-L psychiatry practice.

Fluoxetine in depressed patients on dialysis.

OBJECTIVE: To test the safety and efficacy of fluoxetine in patients with renal failure on dialysis. METHOD: Fourteen patients with major depression and end stage renal disease on hemodialysis were randomized into two groups for an eight-week study. Subjects as well as investigators were blinded as to which subject received fluoxetine and which placebo. Patients were carefully monitored concerning adverse events, serum fluoxetine and norfluoxetine levels, and psychological measurements of degree of depression. RESULTS: No patients discontinued treatment because of adverse events, all of which were minor. All psychological tests showed improvement in depression at the four-week and eight-weeks point, although statistical significance could only be demonstrated at the fourth week of this study. All patients in the active group had serum plasma concentrations of fluoxetine and norfluoxetine less than 250 ng/ml at eight weeks, similar to levels in patients with normal renal function in a previous open label study. CONCLUSIONS: This study confirms the relative safety of fluoxetine in depressed patients in renal failure on hemodialysis. It also suggests that fluoxetine may be efficacious in depressed patients on dialysis.

Fluoxetine in depressed patients with renal failure and in depressed patients with normal kidney function.

Nine depressed patients with normal kidney function and seven depressed patients with renal failure undergoing hemodialysis were treated with open-label fluoxetine 20 mg/day in an 8-week study. The study was designed to evaluate the pharmacokinetics of fluoxetine during repeated administration and to acquire preliminary data regarding the effectiveness of this antidepressant in a population undergoing hemodialysis. Six patients in each group completed the study. Of these, five patients undergoing hemodialysis and five patients with normal renal function experienced moderate to marked improvement in their depression. Side effects were equal and minor in both groups, indicating that fluoxetine is safe in patients with renal impairment. The mean +/- standard deviation steady-state plasma concentrations of the sum of fluoxetine plus its metabolite norfluoxetine for patients completing 8 weeks (N = 6, both groups) were comparable for the patients undergoing hemodialysis (253 +/- 61 ng/ml) and those with normal kidney function (218 +/- 122 ng/ml; t = 1.5, df = 70, p > 0.13). These data suggest that the efficacy of fluoxetine in patients with renal failure undergoing hemodialysis is comparable to that in patients with normal kidney function. These data further suggest that renal failure and the process of hemodialysis do not materially alter the pharmacokinetics of fluoxetine or its major metabolite norfluoxetine.

The effects of renal and hepatic disease on the pharmacokinetics, renal tolerance, and risk-benefit profile of fluoxetine.

Renal and hepatic diseases have a significant impact on the plasma concentration profiles and the dose requirements for almost all drugs. This paper reviews the effect of these diseases and their associated physiological derangements on the pharmacokinetics of fluoxetine and norfluoxetine. Metabolic studies of fluoxetine in man show that more than 70% of the radiolabelled compound is excreted in the urine. Most of the urinary radiolabelled products are metabolites and not the parent compound nor its active metabolite, norfluoxetine. Cirrhosis of the liver significantly reduces the clearance of fluoxetine and norfluoxetine, but mild, moderate, or severe renal dysfunction does not affect fluoxetine or norfluoxetine pharmacokinetics. Daily administration of fluoxetine, 20 mg, for more than 2 months to renally impaired, depressed patients (who require haemodialysis) produces steady-state fluoxetine and norfluoxetine plasma concentrations that are comparable to the concentrations in depressed patients with normal renal function. Renal function is not an important determinant of the steady-state concentrations of fluoxetine or norfluoxetine, though the concentrations may be higher in patients with significantly impaired liver function.

Reintegrating the healed burned adult into society: psychological problems and solutions.

This article reviews important psychosocial factors that effect reintegration of the burned patient into society. Issues of pain, brain injury, the psychological reaction, posttraumatic stress, the impact on the family, and alcohol and substance abuse are discussed, and possible solutions to these problems are offered.

Noncompliance in hospitalized patients with AIDS.

Compliance with treatment is an important concern in the management of patients with a wide array of medical disorders. A chart review of 20 hospitalized AIDS patients at one medical center was done to determine the degree of noncompliance in this extremely ill population. Ninety percent of AIDS patients declined some procedure or treatment, leading to a mean refusal rate of 19.7 refusals per 100 hospital days. Compared to a control population of male leukemics, the mean rate of refusal per hospital day among AIDS patients was over four times greater (p less than 0.05, Student's t-test, two-tailed). Reasons for noncompliance among hospitalized AIDS patients deserve further study.

Identification of psychologic impairment in patients with mild-moderate thermal injury: small burn, big problem.

Sixty-eight patients hospitalized at a tertiary care burn center for more than 1 week, aged 18-32 years, with a mild or moderate burn, adequate social and economic support, and the absence of preexisting psychopathology, substance abuse, or medical illness were studied. From this group 16 patients were identified who had been unable to resume social or occupational functioning even after several months and were impaired by psychologic symptoms related to the burn. Utilizing a psycho-social data base of 250 items, these "Small Burn, Big Problem" (SBBP) patients were compared to those who did not have this problem (control). There were no differences between the two groups with respect to age, sex, race, hospital length of stay, agent of injury, circumstances of the accident, extent of burn, or amount of disfigurement. The SBBP patients did develop significantly more sleep disturbances, which continued into the posthospitalization period. There were significant differences in the use of the defense mechanisms of regression and displacement, the extent of experiencing the injury as a narcisistic injury and in the indication of sexual dysfunction in the SBBP patients as compared to the control group. There were no differences in the amount of psychiatric treatment performed while the patients were in the hospital, although 68% of the SBBP group were referred for psychiatric treatment upon discharge as compared to 14% of the control group. Two case vignettes are presented to demonstrate some of the psychodynamics involved.

Survey of attitudes of nurses working with AIDS patients.

This article reports the results of a ten-question anonymous survey given to nurses at Westchester County Medical Center in July 1983 and January 1984 concerning attitudes about caring for AIDS patients. Two-thirds of the responding nurses reported that they had friends or family express concern about associating with hospital personnel who have contact with AIDS patients. Other questions showed that between one fourth and one half of nurses have a fear of caring for homosexual men and male prisoners because of their awareness about AIDS. One half of the nurses believe that AIDS can be transmitted to hospital personnel because of contact with patients despite precautions. The fear of caring for patients with AIDS as compared to caring for patients with hepatitis, a more contagious but less serious disease than AIDS, was highest in the intensive care unit staff. Eighty-five percent of the health care personnel responding believed that pregnant nurses should not care for AIDS patients and one half of the nurses responding indicated that they would ask for a transfer if they had to care for AIDS patients on a regular basis. The implication of these findings for future treatment programs, medical and nursing education and psychologic support for staff are discussed.

A typology of spousal response to the crisis of severe burn.

Although there has been some discussion in the literature of the psychological responses of spouses during acute and chronic illness, the needs of the spouse and how these may affect psychosocial intervention at the time of acute thermal injury have not been assessed. The behavioral responses of spouses of 25 consecutive burn patients, analyzed retrospectively, were categorized in terms of the manner in which they related to the clinical nurse specialist and other members of the burn team. Three main types are described: Poor Relators, Good Relators, and Over-Relators; the last group comprised two subgroups, the Clingers and the Pseudo-Relators. These interactional styles required specific assessment and management approaches, which are discussed.

Recognizing the role of bereavement and reactive depression in modern psychiatry.

In the modern world the recognition, understanding and treatment of bereavement in recent widows, widowers, those who experienced severe medical and surgical trauma, and victims of disasters is essential for all physicians, rescue workers such as the International Red Cross, and the community in general. This paper reviews the consequences of personal encounters with catastrophic events, as well as methods of immediate and long-term management. Similarly, the dynamic manifestations and treatment of psychologic dissonance in the family of victims, the community, and survivors are addressed. Of special interest are the problems of rescue workers, witnesses and reporters involved in disasters.

Understanding & responding to the terminal patient.

The past ten years have seen a change in the attitudes of informing patients of the diagnosis of a terminal illness. An understanding of the psychological response to physical illness and impending death is required when discussing death and dying with terminal patients. In this article, the authors present generic concepts in understanding the terminal patient, as well as suggested guidelines for the treating physician.

Patients' fantasies about physical illness.

All patients with physical illness have an underlying fantasy concerning why they became sick. This fantasy can be elicited by the consulting psychiatrist and the treating physician. The meaning of the fantasy is consistent with the psychodynamic theory of human behavior. Also, once the fantasy is understood, it can be applied in the patient's therapy.

Current attitudes of medical students and house staff toward terminal illness.

A survey questionnaire about attitudes toward terminal illness was administered to all medical students, interns, and all medical, surgical, and psychiatric residents at the Downstate Medical Center. The majority of students and new physicians surveyed reported that patients with terminal illness should be told their diagnosis--a reversal of attitudes as compared with those revealed by studies done before 1970. Most of the respondents also expressed the view that they would want to be told of their own fatal illness. The attitudes at different levels in medical school, internship, and residency did not differ significantly despite the differences in formal education and clinical experience of the respondents. Implications of these findings are discussed with particular emphasis on the need to teach an individualized approach to the dying patient.

Psychological factors involved in request for elective abortion.

In order to understand the increasing numbers of women who are requesting a repeat elective abortion, 13 First Abortion and 13 Repeat Abortion patients were interviewed. There were no significant differences between the two groups. It was found that the failure of contraception was not because the women did not have access to adequate contraception. There was evidence of underlying psychological conflicts, sometimes in one and even both sexual partners. In 9 of the 26 patients there was material clearly suggesting that the women had an underlying conflictual wish to become pregnant. The data also suggests that many of the male partners had a strong wish to father a child. All of these situations suggest the need for adequate counselling.