Medical implications of employee assistance programmes.

The development of employee assistance programmes (EAPs) has significant implications for doctors, especially general practitioners and psychiatrists. This paper discusses the importance of training counsellors to detect serious psychological disorders among people who use an EAP service and the need for clinicians to accept referrals of those users who are identified as being in need of further medical treatment.

A sense of proportion: the place of psychiatry in medicine.

Psychiatric disorders have a high prevalence in medical and surgical patients and the need for an effective liaison psychiatry service is widely accepted. However, the development of liaison psychiatry may be jeopardised by the trend towards establishing psychiatric facilities in the community rather than in hospitals. Alternative methods of funding may need to be established if the future of liaison psychiatry is to be safeguarded.

Suicide in hospital: guidelines for prevention.

Few events in medical practice create such a sense of failure and guilt as the suicide of a hospital inpatient. The mortality rate is known to be increased in severe psychiatric illness just as it is in most other medical illnesses. The analogy, however, is not generally accepted. Death in cardiovascular or malignant disease, for example, is regarded in many cases as inevitable, a welcome relief from months of pain and suffering. Suicide, by contrast, is considered an unnatural event, one which is avoidable and preventable. In each case of suicide there is a belief among medical and nursing staff that they should have done better: they should have assessed the patient more carefully; been more aware of hints of suicide; provided closer supervision; or not agreed to the final period of leave.

Changes in eating attitudes during the first year of treatment for diabetes.

Eating attitudes were studied in a group of newly diagnosed insulin dependent diabetics. Thirty-two patients completed the eating attitudes test and eating disorders inventory before commencing treatment and 12 months later following routine medical management. There were significant changes in several items, some of which were predicted by virtue of the diet and weight control involved in optimum diabetic management. However, there were also changes in body image which may predispose to the development of eating disorders in this group of patients.

Abnormal eating attitudes in young insulin-dependent diabetics.

All insulin-dependent diabetics between the ages of 16 and 25 years attending the diabetic clinic at the Royal Infirmary, Edinburgh, (152 women and 139 men) were asked to complete the EAT, the EDI, and the GHQ, and to provide a control subject (sibling or close friend) of similar age who would do likewise. Marked differences were found between diabetic women (but not men) and their controls in eating attitudes, in many of the psychological characteristics associated with eating disorders, and in GHQ scores. Although some of the women had classic anorexia nervosa or bulimia, others with abnormal eating attitudes did not fulfil the formal criteria. Overall, diabetics were significantly heavier than controls but the differences in eating attitudes were not eliminated by correcting for overweight. Abnormal scores were associated with high HbA1 levels and independently with retinopathy. The weight gain and psychological effects of diabetes are identified as probably of aetiological importance in the abnormal eating attitudes of young diabetic women.

Clinically apparent eating disorders in young diabetic women: associations with painful neuropathy and other complications.

Of 208 young women with insulin dependent diabetes, 15 (7%) had a clinically apparent eating disorder (anorexia nervosa or bulimia), a much higher prevalence than reported in non-diabetic women. Most, but not all, of these patients had a long history of poor glycaemic control. In contrast with previous suggestions, control did not deteriorate after the onset of the eating disorder. There was a high incidence and an early onset of diabetic complications. Eleven of the 15 patients had retinopathy, six with proliferative changes; six had nephropathy; and six neuropathy. Most strikingly, four patients with anorexia nervosa developed acute painful polyneuropathy. In each case pain started when the eating disorder developed, almost coinciding with the peak of weight reduction. Remission of pain occurred as weight was regained. The symptoms were accompanied by abnormalities in peripheral nerve electrophysiology and autonomic nerve function, some improvements in which accompanied weight recovery. It is suggested that nutritional factors may contribute to the high rate of early onset diabetic complications, particularly neuropathy.

Developments in liaison psychiatry in the United Kingdom.

This paper reviews the organisation of liaison psychiatry in the United Kingdom and discusses the range of clinical problems which liaison psychiatrists undertake. It is suggested that, if services are to expand, more controlled intervention studies must be carried out to evaluate the effectiveness of psychiatry in a general medical setting.

Eating disorders and psychiatric morbidity in patients with diabetes mellitus.

The role of psychological factors in diabetes mellitus is discussed, with particular reference to the influence of eating disorders. The paper describes a prevalence study of eating disorders in outpatients with insulin-dependent diabetes (IDDM) and a controlled questionnaire study of eating attitudes in a similar population. These studies suggest there is a genuine association between eating disorders and IDDM.

Medical admissions in men: the risk among drinkers.

Information on alcohol consumption was elicited by the same method from men in a general population survey and from male medical inpatients in a hospital serving that population. A measure of risk controlling for age, the logarithm of the odds ratio, showed that for liver disorders, upper gastrointestinal disorders, myocardial infarction, other cardiovascular disorders, and respiratory disorders, rising consumption of alcohol was related to increased risk of hospital admission relative to abstention. The risk of admission for the remaining heterogeneous category of disorders was lower than that for abstention, perhaps reflecting the effect of chronic illness on drinking habits, and also suggesting that the link between alcohol consumption and medical diagnoses is not simply due to greater frankness about drinking in hospital inpatients.

Emotional impact of diagnosis and early treatment of lymphomas.

Psychiatric morbidity, relevant symptoms and satisfaction with communication were assessed in patients suffering from malignant lymphoma. Before treatment started 15 of 40 patients had clinically significant psychiatric morbidity. Treatment, in its early stages, was not associated with a significant change in mean psychiatric morbidity scores but there was a decrease in ratings of concern about illness and an increase in ratings of nausea. Eleven of 31 patients seen for a second interview reported dissatisfaction with some aspect of communication with the medical staff. The findings suggest that emotional distress can be contained with a policy of frank communication; nevertheless dissatisfaction is common, being associated with initial less concern, good general health and neurotic personality traits. Personality assessment should be incorporated in future studies of doctor-patient communication.

Attempted suicide by jumping.

A series of 18 patients who attempted suicide by jumping is reported. All were diagnosed as being psychiatrically ill and 14 received psychiatric treatment after the episode. These patients differ in several important aspects from those who harm themselves by drug-overdose.

Distress or illness? A study of psychological symptoms after myocardial infarction.

Three groups of patients were identified during a study of men who had recently suffered an acute myocardial infarction: those with psychiatric morbidity antedating the infarction and those with no significant psychopathology. Compared to the other two groups, patients with psychiatric morbidity before the infarction were more likely to be unmarried, unemployed and to have received previous psychiatric treatment. They also obtained higher scores for neuroticism and psychoticism on personality assessment. Patients whose symptoms have been precipitated by the infarction resembled the psychologically healthy group with regard to their demographic characteristics and personality. Their symptoms tended to be transient, improving without special psychiatric treatment.