Psychobiological aspects of asthma and the consequent research implications.

Recent research suggests that anxiety disorders are more common in asthmatic patients than in the population as a whole. There are a variety of biologic, psychologic, and social factors that suggest that the disorder of asthma may in itself be anxiogenic and that simply having asthma may give patients an increased vulnerability toward the development of anxiety disorders. These issues are reviewed and emphasis is placed on the need for further research into the apparent biologic areas of overlap between psychiatric disorders and asthma. It is hypothesized that a "lactate challenge test" may be used in asthmatics to see if they are predisposed to panic and suggested that a therapeutic trial of tricyclic antidepressants in anxious asthmatics is indicated. Research into the psychobiologic aspects of asthma is likely to clarify the role of "emotional" factors in asthma and may well have significant implications for the management of this disorder.

Psychological defenses and coping styles in patients following a life-threatening attack of asthma.

Twenty-five patients who have suffered a near miss asthma death (NMAD) have undergone a comprehensive psychiatric evaluation on average 13 months following this event. Forty percent of the patients were judged to have psychiatric disorders at the time of assessment. All patients had very high levels of denial and following the NMAD, patients appeared to either decompensate psychiatrically, usually exhibiting symptoms of anxiety disorders, or further increase their levels of denial. Those patients who had psychiatric illnesses at the time of the study were more constitutionally vulnerable towards developing these disorders and had a reduced perception of their quality of life compared with the patients who increased their levels of denial following the NMAD. The effects of the NMAD on patients and their families ranged from mutual anger and anxiety, although the anger was often repressed, to mutual overinvolvement and overdependence. The presence of high levels of denial of asthma and a history of psychiatric illness in the patient appear to be factors that may increase the likelihood of death from asthma.

Characteristics of near-fatal asthma in childhood.

As part of the South Australian asthma mortality survey, we examined 30 cases of near-fatal asthma attacks in children under 15 years of age who were seen over a 3-year period from May 1988 to June 1991. Subjects presented with asthma and either respiratory arrest, PaCO2 above 50 mm Hg, and/or an altered state of consciousness or inability to speak on presentation at a metropolitan Adelaide teaching hospital. A standardized interview and questionnaire was completed with subjects/parents and medical practitioners. Data were reviewed by the assessment panel which made collective judgments based on predetermined criteria. Seventeen patients (57%) were male, 20% were less than 7 years of age, and the majority (53%) were aged between 12 and 15 years. The majority (83%) had severe asthma and only one case (3.3%) had mild asthma. Half of the subjects were waking every night due to asthma and 79% had significant exercise limitation. A quarter of the subjects had a previous ICU admission and 70% had a hospital admission in the last 12 months. Primary care was carried out by a general practitioner in 57% of cases, and 70% of subjects had a crisis plan. Only 46% of those older than 7 years of age had ever used a peak-flow meter. Eighty percent of subjects or their families had high denial scores, and in 73% of cases psychosocial factors were considered to be significant. Eighty percent of cases experienced acute progressive respiratory distress, and 63% of cases delayed seeking medical care.(ABSTRACT TRUNCATED AT 250 WORDS)

Effective treatment of Tourette's syndrome with marijuana.

A single case report is described where marijuana appears to have been an effective treatment modality for symptoms of Tourette's syndrome. Other possible treatment modalities are excluded. It is concluded that there is a need for further work examining the interactions between marijuana, nicotine and the symptomatology of Tourette's syndrome.

Evaluation of a pilot second-opinion child telepsychiatry service.

A second-opinion child psychiatry service was piloted for six months in the northern-most two-thirds of Queensland. It provided specialist expertise by telehealth to local multidisciplinary teams of mental health staff. During the study period, 28 videoconferences were performed by the service: nine for administrative purposes, two for educational purposes, and 17 for direct and indirect clinical applications. The mean time between a referral being made and a consultation being performed was 4.7 days (range 1-13). A survey administered to referring and non-referring mental health workers showed that the major barriers to service implementation included the limited allied health applications that were offered, a perceived lack of communication during the implementation phase of the service, and the creation of a new referral network that did not conform to traditional referral patterns in the north of Queensland.

Telepsychiatry: 'tele' yes, but what about the 'psychiatry'?

To investigate what is lost or gained in a psychiatric evaluation when it takes place via telepsychiatry we compared the interrater reliability between two psychiatrists interviewing 63 subjects in an observer/interviewer split configuration in telepsychiatry and same-room settings. The measures used were the BPRS and interviewer ratings from a semi-structured interview. Patients also rated their experience. There were some clear differences between the telepsychiatry and same-room evaluations. Despite these variations, diagnoses were as reliably made by telepsychiatry. Patient acceptance of telepsychiatry was high.

Telemedicine--clinical applications in mental health.

Video conferences and the Telepsychiatry applications allow for an alternative approach to service delivery in rural areas. They rely heavily on user support and access to a suitably wide network. The ISDN transmission medium is capable of excellent audio and visual quality, but the consequence of this high grade quality is higher transmission costs. Our experiences have so far been positive. No patient has refused to use the medium, nor has any patient walked out of an interview without returning. It is possible to assess patients with a wide range of psychiatric disorders from personality disorders through to frank and severe psychosis. It is hard to see how the system could be used for formal insight oriented dynamic psychotherapy, but there is no reason why it should not be used for review type case management assessments and consultations as discussed in this paper. The interviewing techniques used on Telemedicine require further evaluation but are exciting and interesting, and can probably teach us a great deal about how we might improve our clinical interviewing style. The difficulties in providing equitable services extend beyond access to country centres. Low population densities and cultural diversity, typical for much of remote Australia, demands an alternative approach for effective service provision. While video conferences cannot solve the inequity in service delivery, they can work as a useful adjunct to current service delivery strategies.

The treatment of psychiatric disorders in patients with chronic airways obstruction.

Patients with chronic airways obstruction have been reported as presenting with psychiatric illnesses commonly. The anxiety and depressive disorders, which are the most common psychiatric illnesses, are known significantly to affect patients' level of occupational and social function. Four cases are presented to illustrate the differing presentations of psychiatric illness in patients with chronic airways obstruction. Conventional psychiatric treatment modalities can be used successfully, in spite of severe airways obstruction, and may lead to a markedly improved quality of life for these patients.

Thiamin deficiency and prevention of the Wernicke-Korsakoff syndrome. A major public health problem.

There has been long-standing debate in Australia about the role of thiamin deficiency in the aetiology of the Wernicke-Korsakoff syndrome, the prevalence of the syndrome itself and the preventive measures that might be undertaken to reduce the prevalence rates. A literature review, and the results of a study of the follow-up arrangements of patients who were admitted with Korsakoff's syndrome to the two major South Australian psychiatric hospitals indicate that the syndrome is a major public health problem which requires immediate political intervention. Recommendations are made that a national policy of the fortification of flour and bread with thiamin, as well as of alcoholic beverages, should be implemented.

The future of Australasian psychiatrists: online or out of touch?

OBJECTIVE: The aim of this paper is to examine the delivery of mental health care which will be enabled by the various communications technologies over the next 5 to 10 years. METHOD: A literature review, reviews of multiple Internet websites and the author's personal experience and opinions are combined to provide a commentary on the group of new technologies for communication available within health, and how they will affect the practice of psychiatry and psychiatrists over the next decade. The driving forces for these changes are the rise of consumerism, technological change and financial necessity, and it is evident that patients will have in future much greater choice of access to their therapists than at present. The health-care environment of the future will be different to today, as will the roles of psychiatrists, who will increasingly have to work as members of teams in an expert capacity rather than in traditional one-to-one practice. CONCLUSIONS: It is concluded that it is essential for psychiatrists to become involved in online health care, and in particular to join their patients on the Internet, and that there are major opportunities for Australasian psychiatrists to provide high quality psychiatric care across national boundaries, particularly into the Asia-Pacific region.

Prevention of the Wernicke-Korsakoff syndrome in Australia: a cost-benefit analysis.

The National Health and Medical Research Council (NHMRC) recently has recommended that thiamin be added to cask and flagon wines, fortified wines, beer and flour. This paper presents a cost-benefit analysis of the fortification of alcoholic beverages with thiamin. A total cost-saving in present-value terms of between $60 million and $600 million in 1985 Australian dollars has been calculated. Considerable methodological problems are associated with this type of analysis, and these are discussed. However, the cost-benefit ratio under a range of plausible assumptions remains extremely high--in the region of six to one to 30 to one, or even higher. The methods that are used are compared with those of a 1978 US study, which is appraised critically. The fortification programme that was recommended by the NHMRC is supported strongly on economic grounds.

Safe use of electroconvulsive therapy in pregnancy.

A 22-year-old woman who was 32 weeks pregnant was given a course of electroconvulsive therapy (ECT) as a life-saving measure to treat a severe psychotic illness. The ECT was highly effective and careful monitoring of both the mother and the fetus demonstrated that this was a safe procedure.

The Broken Hill Psychopathology Project.

The main objective of this study was to describe the psychiatric disorders seen in patients presenting for treatment in rural New South Wales. The patients were seen primarily in the community, in both public and private practice, but also in the local base hospital and prison. Seven hundred and seven patients were consecutively examined during the study period. The results of this study were compared with a previous Australia-wide study to identify specific disorders that were more prevalent in rural areas. Alcohol abuse and dependence stood out as being much more prevalent. Life problems such as domestic violence, sexual assault, and incest occurred commonly in women referred for psychiatric assessment. More than ten percent of the study patients were children aged under 17, who had similar prevalence rates of the various psychiatric disorders to a national comparison. It is concluded that alcohol abuse is very common in rural New South Wales, particularly in men, although there are also high rates in women, and this is probably related, in part at least, to the high rates of domestic violence, sexual assault and incest. It appears probable that there is a cycle of alcohol abuse in men leading to domestic violence and sexual abuse in women and children. This may contribute to the latter becoming anxious and depressed. The rates of the major functional psychiatric disorders were similar to those seen nationally. There is a great need for the maldistribution of psychiatrists between metropolitan and rural areas to be addressed.

Telemedicine; here to stay.

Telemedicine is a technology of the future, available today. Here, we describe successful telemedicine systems used across Australia and review barriers to further implementation. Greater academic and multidisciplinary involvement, as well as adequate funding, is needed for the further development and evaluation of these systems.

An examination of the associations between life problems and psychiatric disorders in a rural patient population.

The objective of this clinical study was to examine the differential effects of adversity on pathology. Data obtained from a previously described consecutive series of 707 patients was re-analysed to this effect. A series of specific life events, as well as behaviours that were likely to be secondary to psychiatric disorder, were examined. High rates of life problems such as incest, sexual assault, domestic violence, suicide attempts, and alcohol, tranquilliser and substance abuse were found in the group of patients in general. There were no major differences in the prevalence of these problems in patients with major functional disorders, anxiety disorders, short-lived minor psychiatric disorders, or in "control" patients with no primary Axis I or Axis II diagnosis. Patients with personality disorders as their major psychiatric diagnosis did, however, experience higher levels of the majority of these problems. The clinical implications of the findings are discussed. It is concluded that patients who develop chronic psychiatric illnesses are probably more psychologically or biologically vulnerable than those patients who develop short-lived disorders and who do not achieve a major psychiatric diagnosis from the practising clinician.

A case-control study of the sequelae of childhood sexual assault in adult psychiatric patients.

OBJECTIVE: To determine if there is any association between childhood sexual assault and maladaptive coping behaviour in adult life. DESIGN: A case-control study. SETTING AND PATIENTS: Data from 707 psychiatric patients consecutively examined by one psychiatrist in a rural practice were analysed. Forty-four female patients who were victims of childhood sexual assault were identified and were age matched in a random manner with 88 control patients who denied being sexually assaulted as children. RESULTS: The two groups were similar in occupational level, employment and marital status, and the only diagnostic difference between them was that there was a trend in the sexually assaulted group for more of these patients to be diagnosed as having personality disorder. On a variety of other outcome factors, however, the two groups differed widely. The sexually assaulted women were more frequently victims of domestic violence (odds ratio [OR], 6.4), made suicide attempts (OR, 3.4) and abused alcohol (OR, 3.0) or tranquillisers (OR, 4.6) more often than the non-assaulted women. There was a definite association between childhood sexual assault and maladaptive coping behaviour in adult life, although the association is not necessarily causal, and the childhood sexual assault may, in fact, be a symptom of familial neglect. CONCLUSION: This study provides clear evidence of the need to follow up victims of childhood sexual assault and reinforces the importance of enquiring about this trauma.

Health online: the future isn't what it used to be.

Over the next 10 years, the healthcare system will change to focus more on preventive medicine and healthcare in the home, with fewer doctors and a new class of home healthcare providers. Healthcare professionals need to debate how best to manage these changes.

Abnormal perception of food size in anorexia nervosa.

The hypothesis that patients with anorexia nervosa exaggerate the perceived size of food was tested. Video recordings of five items of food and four neutral objects of a similar size were made such that the size of each object increased steadily from half to twice its normal size. Each of the nine objects was placed on a ledge inside a dummy television screen next to the video screen, the food items alternating with the neutral objects, and 20 female patients with anorexia nervosa and 20 female controls matched for age were asked to adjust the size of the video recording to that of the real object. Although there was no overall difference in perceptual accuracy between patients and controls, both groups perceived the food items as being bigger than the neutral objects, the patients exaggerating the size of the food significantly more than the controls. These results imply that patients with anorexia might start eating more easily when admitted if their food were presented as small portions on large plates.

Psychiatric morbidity in patients with life-threatening asthma: initial report of a controlled study.

Thirteen patients who have suffered a "near-miss" death of asthma have been compared to 36 patients with asthma who had not experienced such an episode. Contrary to expectations, there were no differences between the groups in their levels of psychiatric morbidity, their degree of life-style and social restrictions or in their levels of compliance with prescribed medication. However, both groups did show higher than expected levels of psychiatric morbidity, severe life-style and social restrictions and an unexpectedly-high compliance with prescribed medication. The main psychiatric diagnoses that were noted were anxiety disorders. It is concluded that more comprehensive asthma education and close medical follow-up are likely to improve the physical and psychological health of asthmatic patients. The high-risk patients in this study who received such follow-up have shown hospital-admission rates that have been reduced by a half while maintaining good asthma control. This South Australian longitudinal study is continuing.

Psychiatric morbidity in patients with chronic airflow obstruction.

Fifty consecutive patients with chronic airflow obstruction who were admitted to a respiratory unit were assessed medically and psychiatrically. A high rate of psychiatric morbidity (58%) was detected with panic and other anxiety disorders (34%) being particularly prevalent. Various physiological and psychological reasons for the high rate of anxiety disorders are discussed.