Continuing medical education in mental illness: a paradox for general practitioners

BACKGROUND: In 1992, the Royal College of General Practitioners instituted its fellowship in mental health education, which aimed to provide general practitioner tutors with the skills they need to help general practitioners manage mental illness in general practice. However, the emphasis of the fellowship on pedagogic education may discourage educators wishing to introduce andragogic teaching, a paradox which general practitioners must resolve if the aims are to be realized. AIM: This study set out to follow the difficulties encountered by the regional fellows in managing the fellowship and to understand how the scheme has evolved. METHOD: Data collected for interim evaluation of the fellowship was studied and interviews undertaken with the senior fellow and the regional fellows participating in the scheme. RESULTS: From its beginnings, the project encountered difficulties involving acceptance among general practitioner tutors. In response to the objections raised, the project metamorphosed through three stages, from a (perceived) pedagogic approach to a much more overtly learner-centered one. CONCLUSION: Learner-centred education requires trust and belief in the ability of general practitioners to teach general practitioners; over-protection of the audience from 'non-expert' educators merely perpetuates the status quo. If education in mental health care is to become truly learner-centred, general practitioners must address this paradox.     

General practitioners'' attitudes to psychiatric and medical illness

BACKGROUND: General practitioners are increasingly involved in the care of patients with long-term psychiatric disorders. We have previously reported that general practitioners are less willing to treat patients with schizophrenia than those without such a diagnosis, but this may have been attributable to a reluctance to treat patients with any psychiatric or chronic illness. We, therefore, examined general practitioners' attitudes to patients with chronic psychiatric or medical illnesses. METHODS: A random sample of 260 local general practitioners were each sent one of our case vignettes which were identical apart from mention of a previous diagnosis of schizophrenia, depression, diabetes or no illness. The general practitioners were asked to indicate their level of agreement with 13 attitudinal statements based on the vignette. RESULTS: One hundred and sixty-six (66%) of the general practitioners responded to the case vignettes. Those responding to the vignette about the patient with schizophrenia were less happy to have that patient on their practice list and were more concerned about the risk of violence and the child's welfare. Those responding to the depression vignette were more likely to offer the patient antidepressants or counselling; and those who replied to the diabetes case were most likely to refer the patient to a hospital specialist. These differences were not attributable to the personal or practice characteristics of the general practitioners. CONCLUSIONS: Patients with schizophrenia arouse concerns in general practitioners that are not simply due to those patients suffering from a psychiatric or chronic illness. Our results suggest that some patients with schizophrenia may find it difficult to register with a general practitioner and receive the integrated community-based health care service they require. Psychiatrists should provide education and support to general practitioners who look after patients with schizophrenia.     

Communication in general practice: recognition and treatment of mental illness

The scope of the present review is to describe epidemiology, classification, symptomatology and treatment of diabetic peripheral somatic neuropathy and autonomic neuropathy. Special attention is paid to the use of local anaesthetic agents in painful diabetic neuropathy. Denervation hypersensitivity is a characteristic of autonomic neuropathy in diabetic patients. The pathophysiology behind this phenomenon is elucidated in this review and most recent studies related to diabetic encephalopathy are reviewed. References for this review were acquired via a MedLine and MedLars literature search.     

Gender differences in psychiatric illness and treatments: a critical review

Controversy exists about the causation of gender differences long observed in the prevalence of mental disorders. Recent epidemiological, biochemical, and genetic research has shed further light upon both their etiologies and treatments. Both controversies and research are reviewed and critically examined.     

Humanizing a psychiatric ward: Changing from drugs to psychotherapy.

Describes the transition and change of a psychiatric ward from primary reliance on drugs to an intensive psychological approach. There were both strong institutional supports and resistances reflecting the ambivalence attending efforts to develop more personal, humanized ways of relating to mental patients. An open ward community setting evolved in which staff became highly accessible and caring, patients shared major caring and treatment responsibilities, and certain special psychological treatment techniques were developed. Many previously "untreatable" patients were involved, and the improvement criteria were ambitious. Results suggest that such an approach is superior in long-term cost/benefit effectiveness to the prevalent "revolving door" programs that emphasize drugs and "dischargeability." (15 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

WAIS—R factor structure in psychiatric and general medical patients.

Examined the factor structure of the WAIS—R in a sample of 200 general medical (GM) patients and 271 psychiatric patients. The mean age of the Ss was 38.9 yrs. Results of 2- and 3-factor principal factor solutions with varimax rotations were compared to the factor structure of the WAIS—R normative sample (n?=?1,880) and a sample of vocational counseling patients (n?=?84), as well as an additional sample of psychiatric patients (n?=?114). Across all of these samples, coefficients of congruence for the 1st 2 factors (Verbal, Performance) were .97 or greater, and coefficients of congruence for the 3rd factor (Freedom From Distractability) ranged from .93 to .97. Results indicate that the WAIS—R has a robust factor structure and provides empirical evidence for the existence of Verbal, Performance, and Freedom From Distractability factors on the WAIS—R in psychiatric and medical populations. (13 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The psychiatric model: a critical analysis of its undermining effects on nursing in chronic mental illness

Nursing has incorporated many aspects of the medical model in forming nursing practice. I argue that this conception has not resulted in an effective approach for patients with mental illness, especially those with chronic mental illness. In attempting to formulate practice, nurses are impeded by the constraints of this almost universally accepted model, perhaps in ways that have evaded conscious awareness. Patients, also, must try to live their lives within limited options imposed by professional people who supposedly have their best interest at heart. This article identifies the assumptions of the psychiatric medical model and shows how using this narrow, received format is inconsistent with nursing practice. The author delineates the process of her awakening to its undermining effect on her relationships with patients and offers suggestions for more appropriate practice in chronic mental illness.     

Basic principles of cost-benefit analysis in long-term treatment of risk factors

Health care decision makers are increasingly forced to identify and implement the options for potential spendings and savings. Historically, preventive measures for cardiovascular diseases have been scrutinised a great deal. The main reason for this was that substantial financial investments would have to be undertaken long before the clinical benefits were apparent. In the past, most economic evaluations of lipid lowering therapy have been based on models combining logistic regression risk functions from epidemiological cohort studies, such as the Framingham study, with the extent of cholesterol reduction. Recently, however, data from the large controlled outcome studies (4S, CARE, LIPID, WOSCOPS) have been reported which allow a direct estimate of the economic benefits of cholesterol reduction in primary and secondary prevention. The economic evaluation of such therapies can be performed in several ways, from relatively easy cost-consequence analyses to more complex cost-effectiveness analysis. Initial economic analyses of the trials are already available. There are, however, still considerable practical and methodological issues which have to be taken into account in assessing lipid lowering drugs. Available pharmaco-economic data on lipid lowering therapies suggest that statins are a cost-effective option in primary and secondary coronary prevention.     

Predictors and outcome of discharge against medical advice from the psychiatric units of a general hospital

OBJECTIVE: The study examined predictors of discharge against medical advice (AMA) and outcomes of psychiatric patients with AMA discharges, as measured by poorer symptom ratings at discharge and higher rates of rehospitalization. METHODS: A total of 195 patients discharged AMA from general hospital psychiatric units were compared retrospectively with 2,230 regularly discharged patients. AMA status was defined as signing out against medical advice, being absent without leave, or being administratively discharged. All patients received standardized assessments within 24 hours of admission and at discharge. Demographic characteristics, psychiatric history, DSA-IV psychiatric and substance use diagnoses, and scores on an expanded 32-item version of the Psychiatric Symptom Assessment Scale were compared. RESULTS: The groups did not differ in primary psychiatric diagnoses. Patients discharged AMA were significantly less likely to be Caucasian or to be functionally impaired due to physical illness. They were more likely to live alone, have a substance use diagnosis, use more psychoactive substances, and have more previous hospitalizations. Patients discharged AMA had significantly shorter lengths of stay, higher rehospitalization rates, and more severe symptoms at discharge, even when length of stay was taken into account. The differences between the groups in male gender and young age were better accounted for by a greater likelihood of substance abuse in these groups. CONCLUSIONS: The results suggest a profile of patients who may be discharged AMA. Such patients have worse outcomes and are more likely to be high utilizers of inpatient resources. Aggressive identification of patients likely to be discharged AMA and early discharge planning for appropriate outpatient treatment are recommended.     

Parents judgement concerning family work of a child psychiatric ward

This study focused on the role of the baroreceptor-mediated control during the compensatory process after acute left ventricular overloading induced by aortic regurgitation (AR). Baroreceptor-heart rate sensitivity was measured using a phenylephrine-induced increase in blood pressure according to the steady state method before, 1 day, 1 week and 4 weeks after production of AR in 7 rabbits, and compared with 6 other rabbits that underwent a sham operation. Blood pressure was monitored noninvasively using Finapres in the unanesthetized state. Four weeks after the procedure, the left ventricular diameters of both end-diastole and end-systole were larger in the rabbits with AR than in the sham-operated rabbits. There was no difference in the left ventricular end-diastolic pressure or cardiac output. Left ventricular weight was higher in the rabbits with AR than in the sham-operated rabbits. Myocardial beta-adrenergic receptor density and norepinephrine content were comparable between the two groups. Baroreceptor-heart rate sensitivity significantly decreased 1 week after production of AR, and this alteration in sensitivity was partially restored 4 weeks after production of AR. These findings suggested that the altered baroreceptor-heart rate sensitivity was reversible, relating to the compensatory process after acute left ventricular overloading, and that these changes had some role in its pathophysiology.     

Family functioning and mental illness: a comparison of psychiatric and nonclinical families

The primary objective of the present investigation was to examine adaptive functioning in the families of patients with a wide range of psychiatric disorders. Seven dimensions of family functioning, as measured by the Family Assessment Device (FAD), were compared across families of patients with a schizophrenia spectrum disorder (n = 61), bipolar disorder (n = 60), major depression (n = 111), anxiety disorder (n = 15), eating disorder (n = 26), substance abuse disorder (n = 48), and adjustment disorder (n = 46). Families in each psychiatric group were also compared to a control group of nonclinical families (N = 353). Results indicated that regardless of specific diagnosis, having a family member in an acute phase of a psychiatric illness was a risk factor for poor family functioning compared to the functioning of control families. However, with few exceptions, the type of the patient's psychiatric illness did not predict significant differences in family functioning. Thus, having a family member with a psychiatric illness is a general stressor for families, and family interventions should be considered for most patients who require a psychiatric hospitalization for either the onset of, or an acute exacerbation of, any psychiatric disorder.     

Beliefs about mental illness as a functon of psychiatric status and psychiatric hospitalization.

Beliefs about mental illness were assessed among psychiatric inpatients at a VA hospital, the mental health staff responsible for their treatment, and a group of medical and surgical (control) patients. Results indicated that: (a) Psychiatric and nonpsychiatric patients generally hold similar opinions regarding mental illness. Severely disturbed psychiatric patients, however, view mental illness in more moralistic terms than do "normals." (b) Psychiatric hospitalization is generally accompanied by a change in the patient's beliefs concerning mental illness, toward those held by the staff. (c) Psychiatric patients whose beliefs about mental illness are most strikingly influenced by the staff tend to respond most favorably to treatment, as measured by length of hospital stay and gains in self-esteem during the 1st month of treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive-behavioral treatment of panic complicated by medical illness.

Notes that cognitive-behavior therapy combined with medication can be an effective treatment combination for individuals suffering from panic attacks. Certain cases may prove difficult however, particularly when an individual is recovering from a serious medical illness in which many of the symptoms of the medical illness overlap with the symptoms of panic. This article reviews some of the complicating factors that may occur with such cases as well as techniques for helping individuals differentiate between symptoms that denote a recurrence of the medical illness and those that involve panic disorder and anxiety. Two case vignettes, one of a 54-yr-old steel worker and one of a 19 yr-old gymnast, are included that portray how cognitive-behavioral techniques can be used to help individuals reduce their anxiety and panic and also effectively differentiate symptoms of a recurring medical illness. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Primary psychiatric illness in a neurological out-patient department in North-East England

A Gram-negative bacillus that defies identification was isolated from blood cultures of 17 patients with fever. Fifteen patients were male adults, and 14 patients had underlying diseases, including previous splenectomy in five, which impair host defenses against infection. Illnesses occurred in the summer and autumn in 14 cases and had been recently preceded by dog bites in 10 cases. Clincal syndromes included cellulitis in seven cases, primary bacteremia without localization in four, purulent meningitis in four, and endocarditis in three. Three patients died. The organism grows slowly on blood or chocolate agar in 10% CO, is oxidase- and catalase-positive, and is negative for nitrate reduction, indole production, and urease. It produces acid from glucose, lactose, and maltose. These features distinguish it from all previously described and classified bacteria. Furthermore, the epidemiologic features of the patients suggest that this organism is an opportunistic invader and may have an animal reservoir in nature.     

Pharmacologic management of psychiatric illness during pregnancy: dilemmas and guidelines

OBJECTIVE: Given concerns about use of psychotropic medication during pregnancy, the authors reviewed the literature regarding the effects of prenatal exposure to psychotropic medications on fetal outcome. METHOD: A MEDLINE search of all articles written in English from 1966 to 1995 was performed to review information on the effects of psychotropic drug use during pregnancy on fetal outcome. Where sufficient data were available and when methodologically appropriate, meta-analyses were performed to assess risk of fetal exposure by psychotropic medication class. RESULTS: Three primary effects are associated with medication use during pregnancy: 1) teratogenicity, 2) perinatal syndromes (neonatal toxicity), and 3) postnatal behavioral sequelae. For many drug classes there are substantial data regarding risk for teratogenicity. Tricyclic antidepressants do not seem to confer increased risk for organ dysgenesis. The available data indicate that first-trimester exposure to low-potency phenothiazines, lithium, certain anticonvulsants, and benzodiazepines may increase the relative risk for congenital anomalies. However, the absolute risk of congenital malformations following prenatal exposure to most psychotropics is low. CONCLUSION: Exposure to certain psychotropic drugs in utero may increase the risk for some specific congenital anomalies, but the rate of occurrence of these anomalies even with the increased risk remains low. Use of psychotropic medications during pregnancy is appropriate in many clinical situations and should include thoughtful weighing of risk of prenatal exposure versus risk of relapse following drug discontinuation. The authors present disorder-based guidelines for psychotropic drug use during pregnancy and for psychiatrically ill women who wish to conceive.     

Special series: Coping with medical illness and medical procedures.

This Special Series integrates recent progress in coping processes with the challenges of behavioral medicine. The term coping implies a reaction to stress; this series of articles considers stressors such as chronic disease (hypertension, heart disease, and arthritis), disability and death, and medical procedures (radiation therapy, childbirth, surgery, and invasive diagnostic procedures). Each study has derived a unique set of conclusions, with the common theme that preconceived notions about coping effectiveness should be replaced by empirical exploration. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Screening for psychiatric illness with a combined screening and diagnostic instrument

OBJECTIVE: To determine 1) if the PRIME-MD, a two-step screening and diagnostic instrument for psychiatric disorders, increases diagnosis and intervention when actively implemented in a busy general medicine clinic, and 2) the type of staff support required to achieve sufficient implementation to realize gains in diagnosis and treatment. DESIGN: We introduced the PRIME-MD into a large general medicine clinic with repeated rotation of four support conditions for implementation: (1) no support, (2) nonclinical staff support (NCSS), (3) nursing staff (RN) support, and (4) a written "Prompt" condition. SETTING AND PATIENTS: Patients (N = 2,263) attending a general medicine clinic at a Veterans Affairs Medical Center. MEASUREMENTS AND MAIN RESULTS: Outcome measures were (1) PRIME-MD questionnaire and interview use, (2) overall psychiatric diagnosis, (3) new psychiatric diagnosis, and (4) provider intervention for psychiatric conditions. The NCSS, RN support, and prompt conditions resulted in similar rates of questionnaire use but significantly different rates of structured interview use. The NCSS condition was associated with significant increases in new diagnosis, and the RN support and Prompt condition were associated with significant increases in new diagnosis and intervention compared with no support. CONCLUSIONS: Nursing staff support resulted in sufficient PRIME-MD implementation to achieve gains in both new diagnosis and provider intervention compared with no support. These gains occurred in a busy primary care clinic with nonselected providers and customary visit lengths. This level of support should be achievable in most clinical settings.