Alleviating the shortage of physicians.

A curriculum is described whereby qualified Ph.D's can become M.D.'s within a period of 18 to 24 months. It is feasible and logical not only for us, but for other schools of medicine. It is our belief that adequate safeguards have been included to preserve high quality in education while responding to the need not only for more physicians, but also for improved utilization of some of our best-trained manpower.

Recombinant human granulocyte colony-stimulating factor hastens granulocyte recovery after high-dose chemotherapy and autologous bone marrow transplantation in Hodgkin's disease.

To determine whether recombinant human granulocyte colony-stimulating factor (rhG-CSF) can accelerate granulocyte recovery after high-dose combination chemotherapy with autologous bone marrow transplantation (ABMT) in patients with Hodgkin's disease, we performed a nonrandomized phase II study using historical controls as a comparison. Eighteen relapsed/refractory Hodgkin's disease patients who received cyclophosphamide at 1.5 g/m2/day (days -6 to -3), carmustine (BCNU) at 300 mg/m2 (day -6), and etoposide (VP-16) at 125 mg/m2 every 12 hours (days -6 to -4), followed by ABMT (day 0) were treated with rhG-CSF at 60 micrograms/kg/day for a maximum of 28 days beginning on day 1. rhG-CSF dosage was gradually diminished and stopped once an adequate granulocyte count was maintained. rhG-CSF significantly accelerated absolute granulocyte count (AGC) compared with historical controls recovery to the 100/microL level (median, 9 days v 13 days; P = .103 x 10(-4), 500/microL level (median, 13 days v 22 days; P = 0.189 x 10(-2), and 1000/microL level (median, 16 days v 30 days levels; P = .125 x 10(-5). Platelet recovery to 50,000/microL was not significantly altered (P = .370). rhG-CSF was well tolerated, bone pain and myalgia being the only side effects noted. rhG-CSF hastens granulocyte recovery after high-dose chemotherapy with ABMT in patients with relapsed/refractory Hodgkin's disease without significant toxicity.

Contrasting models for combined medical and psychiatric inpatient treatment.

The authors contrast the clinical, administrative, and reimbursement aspects of two units offering combined medical and psychiatric inpatient treatment, one under medical auspices (the medical/psychiatric model), the other under psychiatric auspices (the psychiatric/medical model). The typical patient on both units suffered from depression with prominent somatic symptoms. The psychiatric/medical model was clinically advantageous because of its greater capacity for containing agitated, psychotic, and suicidal behavior and because of its potentially longer lengths of stay for refractory patients. Furthermore, the psychiatric/medical model offers more predictable payment for psychotherapy under fee-for-service insurance and is less likely to be adversely affected by the current prospective payment system based on diagnosis-related groups.

Major depression versus organic mood disorder: a questionable distinction.

DSM-III-R requires the exclusion of causal organic factors to permit a diagnosis of major depression. This exclusion criterion may be unreliable because (1) neither the biomedical nor the historical data base for determining organic causation is operationally specified, (2) rules for weighting various causes of depression are not specified, and (3) the distinction between causal and contributory organic factors often is arbitrary. The exclusion criterion may not be valid because (1) it is unstable with time and (2) clinical criteria for CNS involvement may correlate poorly with neurodiagnostic tests. Both reliability and validity of diagnosis would be improved by keeping Axis I strictly phenomenological and identifying relevant organic factors on Axis III.

Age, medical illness, and the DST in depressed general hospital inpatients.

A dexamethasone suppression test (DST) was administered to 89 general hospital inpatients as part of an evaluation of depressed mood. Among the 55 patients with major depressive disorder (MDD), age was positively correlated with postdexamethasone cortisol (r=.317, p=.002 at 4 p.m.). The patients without MDD did not show this effect. Postdexamethasone cortisol concentrations of 15 micrograms/dl or greater were seen in 31% of 32 patients over 60 with MDD; they did not occur in 23 patients under 60 with MDD. The results suggest a clinically relevant effect of age on the DST in patients with MDD.

Personality disorder diagnoses and age in inpatients with major depression.

To ascertain the prevalence of personality disorder in elderly patients with major depression and to explore issues of diagnostic practice and bias, the authors reviewed triaxial diagnoses of 2322 psychiatric hospital inpatients with Axis I diagnoses of major depression. They found that Axis II diagnoses had been made in 367 cases (15.8%). Patients older than 65 years of age had a significantly lower rate of Axis II diagnoses. The age effect was greatest for women with comorbid physical illness. In contrast to the age-related decline in rate of Axis II diagnoses in general, the diagnosis of compulsive personality disorder increased with age and comprised 46% of all Axis II comorbidities in patients 65 years or older. Possible explanations and implications for future research are discussed.

Sleep apnea and hypothyroidism presenting as depression in two patients.

Two patients are described who presented with depression and were later found to have both obstructive sleep apnea and hypothyroidism. Both patients had normal thyroxine (T4) levels but elevated thyroid-stimulating hormone (TSH) levels. Thyroid replacement led to resolution of both apnea and depression. The possibility of hypothyroidism as a cause of sleep apnea and depression is discussed.

Depression as a manifestation of obstructive sleep apnea: reversal with nasal continuous positive airway pressure.

Fifty-five patients with obstructive sleep apnea each completed a Zung Self-Rating Depression Scale (SDS), Twenty-five patients (45%) had SDS scores greater than or equal to 50, consistent with depression. The SDS scores did not correlate with age, the number of respiratory events per hour sleep, antihypertensive medication, or the oxygen saturation baseline or nadir. The group with SDS scores of 50 or greater, however, had 68.0 +/- 8.8 respiratory events per hour compared with 47.9 +/- 4.7 in the group with SDS scores under 50 (p less than .05). Nineteen patients who were treated with nasal continuous positive airway pressure completed a follow-up SDS Inventory. After treatment, the SDS scores fell from 60.5 +/- 1.9 to 44.4 +/- 2.6 (p less than .001) in the 11 patients with baseline elevated scores. The authors conclude that obstructive sleep apnea can produce prominent symptoms of depression that appear to be related to the severity of the underlying apnea; furthermore, treatment of obstructive sleep apnea may result in alleviation of these symptoms in certain patients.

Coping and depressive symptoms among people with AIDS.

This study examined coping behaviors of people with AIDS, using a large sample (N = 736) that was both geographically and sociodemographically diverse. In-person interviews were conducted with people receiving AIDS-related medical or social services; follow-up interviews were conducted approximately 11 months later. Factor analyses of 16 coping behaviors revealed three factors: Positive Coping, Seeking Social Support, and Avoidance Coping. Respondents with a history of injected drug use, as compared with gay or bisexual men, had higher scores for Avoidance Coping and lower scores for Positive Coping. Each coping scale was significantly related to depressive symptoms in cross-sectional analyses. In longitudinal analyses that controlled for prior depressive symptoms, Positive Coping was significantly related to decreases in symptoms.

A psychiatric unit becomes a psychiatric-medical unit: administrative and clinical implications.

Increasing awareness of the frequent concurrence of medical and psychiatric illness has led to a resurgence of interest in psychiatric-medical units. This paper describes the conversion of a 19-bed general hospital psychiatric unit to a psychiatric-medical model. The conversion involved hiring a full-time chief and changing priorities for elective admission, but did not involve major changes in staffing; community-based psychiatrists continued to admit the majority of patients. Arrangements were made for medical house staff coverage of emergent medical problems, while daily medical care remained in the hands of the psychiatrists and their private medical consultants. In the year following the transition numerous patients with combined acute medical and psychiatric illness not treatable in the previous model were accepted and successfully treated. Quantitative study of annual statistics from the pre- and posttransition years revealed the following: The average age of patients increased from 46 to 54 years. The proportion of patients over 65 increased from 19% to 34.9%. The proportion of patients with identified concurrent medical diagnoses increased from 54.7% to 69.1%. Dispositions to nursing homes and chronic care facilities decreased from 10.5% to 8.9%. Length of stay increased from 19.3 to 23.1 days. The average daily hospital bill for psychiatric inpatients rose by 24.6%, compared with a hospital-wide average increase of 16.3%. Although the change in model appeared to offer effective treatment to previously underserved patients, it implied a significant shifting of patients and of costs. Administrative implications are discussed, and a list of preconditions for a successful conversion are suggested.

Med-psych units. Financial viability and quality assurance.

Although medical-psychiatric units may have unique advantages for treating patients with combined medical and psychiatric illness, they may be costly to run, and their success requires a sound financial basis. This begins with filling beds and instituting a waiting list, and then setting admission priorities to regulate case mix deliberately to address financial as well as ethical and clinical considerations. Development of short-stay geropsychiatric evaluation services may offset financial problems associated with long stays of elderly patients requiring definitive treatment for complex conditions. Data are presented to show the effectiveness of deliberate regulation of case mix. Regarding quality assurance, key issues include maintaining documentation to meet HCFA standards for DRG exemption, and effectively integrating physical and psychiatric care, with a special focus on drug interactions and psychiatric toxicities of medical drugs. Effective multidisciplinary treatment planning meeting help in this effort, as do periodic walking rounds focusing specifically on pharmacologic issues. Denials of payment by third parties are most likely to be a problem when both the medical and the psychiatric illness are subacute but their interaction requires conjoint inpatient treatment. Prospective work with PROs can minimize retrospective denials.

Depressed mood and care preferences in patients with AIDS.

Eight hundred ninety-seven patients with AIDS seen in ambulatory settings were questioned about whether they would accept a nursing home or a respirator if necessary to prolong their lives. Two hundred ninety-one (32.9%) said they would accept a nursing home; 102 (11.5%) said they would accept a respirator. Acceptability of these life-sustaining interventions was significantly lower in those patients who showed evidence of clinical depression on a structural screening instrument (nursing home: 29.4% vs 39.5%, p = 0.002; respirator: 9.4% vs 14.3%, p = 0.032). Depression remained significant in multivariate models of care preferences that controlled for demographics and symptom severity. Based upon follow-up interviews conducted an average of 11 months later, subjects who were initially depressed and found nursing home care unacceptable were significantly more likely to have changed their minds at follow-up if their depression was no longer present (45.7% vs 28.4%; p = 0.0005). Findings for respirator preferences were similar, but did not attain significance. We conclude that assessment for depression is essential when advance directives for care are elicited from patients with AIDS.

The association of normal-pressure hydrocephalus with obstructive sleep apnea.

This report describes a 70-year-old man with obstructive sleep apnea who deteriorated rapidly when nasal continuous positive airway pressure was begun. The patient was found to have normal-pressure hydrocephalus, which was possibly exacerbated by the nasal continuous positive airway pressure. A review of the literature indicates several significant associations between apnea, normal-pressure hydrocephalus, and increased intracranial pressure and suggests that the association of obstructive sleep apnea and hydrocephalus might not be rare. Implications for diagnosis and treatment are discussed.

Occurrence of high concentrations of postdexamethasone cortisol in elderly psychiatric inpatients.

The authors retrospectively studied 161 psychiatric inpatients who had received a dexamethasone suppression test (DST). The majority of the patients were over 60 years old, female, and had concurrent chronic medical illnesses. Age was significantly correlated with log-transformed postdexamethasone cortisol concentrations in the 118 nondemented patients with major depression. Four p.m. cortisol concentrations greater than 15 micrograms/dl occurred in 15 patients. All were over 60 years old; all but one had major depressive disorder (MDD); and five had dementia plus MDD. In the same population, a 5 micrograms/dl criterion did not distinguish MDD from non-MDD patients. The results support the existence of a clinically relevant age effect on the DST in patients with MDD. Elderly depressed patients with markedly elevated cortisol concentrations occur frequently, and warrant further clinical and pathophysiological study.

Characteristics of nursing homes that are restraint free.

Using nationally representative data from the On-line Survey and Certification of Automated Records (OSCAR) and the Area Resource File (ARF), comprising 15,074 nursing homes, the differences between restraint free and non-restraint free nursing homes were examined. Restraint free nursing homes were found more likely to have residents with less ADL deficiencies and lower average numbers of residents who were bowel or bladder incontinent. They were more likely to be not-for-profit, smaller, low occupancy facilities that did not belong to nursing home chains, and were located in urban and more competitive areas. With regard to staffing factors, restraint free facilities had a richer mix of nursing staff, although the total number of staff per resident did not differ. Restraint free facilities were likely to utilize more full-time equivalent (FTE) registered nurses (RNs) per resident, but less FTE nurse aides and licensed practical nurses (LPNs) per resident. Psychoactive drug use rates did not differ between the types of homes.

Risk factors for physical restraint use in nursing homes: pre- and post-implementation of the Nursing Home Reform Act.

The purposes of this article are (1) to identify resident and facility risk factors for the use of physical restraints since the implementation of the Nursing Home Reform Act (NHRA), and (2) to compare these results with resident and facility risk factors for the use of physical restraints prior to the implementation of the NHRA. Data were collected in 1990 and 1993, and represent residents drawn from 268 facilities in 10 states. In the 1993 cohort activities of daily living (ADL) scores, cognitive performance scale (CPS) scores, age, taking antipsychotic medications, a history of falls, and mobility problems were resident-level variables significantly associated with the use of restraints. Full-time-equivalent (FTE) nurse aides per resident, FTE RNs per resident, average occupancy, Herfindahl index, Alzheimer's special care unit, and Medicaid reimbursement policy were facility-level variables significantly associated with the use of restraints. When the 1990 cohort was compared to the 1993 cohort (pre- and post-NHRA), however, only three risk factors for the use of restraints were significant. We propose that, to date, the NHRA may have been successful in reducing the use of physical restraints, but it appears to have had less impact on the types of residents who are restrained.