The utility of interdisciplinary training and service: Psychology training on a psychiatry consultation-liaison service.

Increasing numbers of psychologists work in medical settings because of the growing acceptance of a biopsychosocial approach to illness. Do training programs prepare sufficient numbers of graduates to function effectively in medical settings? The authors describe the process of adding an inpatient medical-surgical consultation-liaison (C-L) service to a psychology internship's training rotations, the learning objectives used, and issues in the preparation of trainees for work in medical settings. Psychology trainees added significant capacity to the C-L service. These data may help facilitate the development of C-L training experiences for other programs (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Internet and the future of psychiatry

OBJECTIVE: The Internet is a rapidly growing communications resource that is beginning to have an impact on medicine, and it is anticipated that the Internet will soon have a major effect on psychiatry. It is essential for psychiatrists to have a conceptual framework for understanding the many aspects of the Internet. METHOD: Using a four-layer model, the authors describe the components of the Internet and how these work together to establish communication. They discuss some of the practical implications of the model, potential future applications of the Internet, and some of the challenges its use will create. RESULTS: In the Internet model described, the bottom three layers involve hardware and modes of information transmission; the fourth layer is human interaction. The Internet has great potential in psychiatric education, clinical care, research, and administration, but major adjustments in individual and organizational expectations and responses will be needed. These changes relate to the speed, dispersion, volume, privacy, and permanence of communication. CONCLUSIONS: The growth of the Internet and related information technologies is inevitable and has diverse technical and social implications. As psychiatrists, we must remain effective communicators of information and adjust to a changing world with new roles and skills that will permit us to best serve our professional mission.     

Recent-onset ecstasy use: Association with deviant behaviors and psychiatric comorbidity.

Background: Despite increases in ecstasy (MDMA) use in the United States, little is known about characteristics linked with recent-onset ecstasy use, especially psychiatric symptoms and deviant behaviors. Aims: To test whether individuals with high levels of other drug use are more likely to be recent-onset ecstasy users; to test whether psychiatric symptoms in adults are associated with recent-onset ecstasy use; to explore the association between recent-onset ecstasy use and concomitant deviant behaviors in adolescents and adults. Methods: Data from the 2001 National Survey on Drug Use and Health. Findings: Recent-onset ecstasy use was significantly more likely to occur among adolescents and adults (18-34 years old) who engaged in deviant behaviors during the past year as compared with those who did not engage in deviant behaviors during the past year. Higher levels of deviancy indicated a higher likelihood of being a recent-onset ecstasy user, and associations were strongest with nonviolent deviant behaviors such as selling illegal drugs and stealing. Associations between deviant behaviors and recent-onset ecstasy use were similar in strength to associations between deviant behaviors and recent-onset cocaine and marijuana use, respectively. Adults who had past-year psychiatric symptoms (both depressive and panic symptoms) were twice as likely to be recent-onset ecstasy users as compared with those without past-year psychiatric symptoms. Greater levels of drug involvement increased the odds of being a recent-onset ecstasy user. Conclusion: Recent-onset ecstasy use seems to be associated with a range of other behavioral problems and may reflect one aspect of a larger problem behavior syndrome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The future of psychiatric hospitals

We are of the opinion that it is less important whether a large mental hospital is regionalized or not, but whether it is possible to realize the principle of universal psychiatric protection as a "unity of responsibilities of all subjects who take part in the protection of mental health and the society in the whole" by improvement and advancement of the existing system. We accept the opinion that the internal organization of mental hospitals has to be changed by organizing hospitals wards with 30-50 beds. We consider that in a perspective organization of psychiatric protection of all institutions (large hospitals, clinic, psychiatric wards of general hospitals, dispensaries and health centers) have their role and that the achieved level of the protection greatly depends on socio-economic level and possibilities.     

Marital dissatisfaction and psychiatric disorders: Results from the national comorbidity survey.

The association between marital dissatisfaction and 12-month prevalence rates of Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev., 1987) Axis I psychiatric disorders was examined in married respondents from the National Comorbidity Survey (N?=?2,538). Results indicate that marital dissatisfaction was associated with the presence of any disorder, any mood disorder, any anxiety disorder, and any substance-use disorder; dissatisfaction was also associated with 7 of 12 specific disorders for women and 3 of 13 specific disorders for men. To evaluate the unique association between marital dissatisfaction and psychiatric disorders, analyses were conducted controlling for comorbid disorders. Covariance analyses generally attenuated the bivariate associations between marital dissatisfaction and specific disorders and groupings of disorders. Results indicate that marital dissatisfaction was uniquely related to major depression and posttraumatic stress disorder for women and dysthymia for men. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Depression in general medical settings. Implications of three health policy studies for consultation-liaison psychiatry

Prepaid or prospective reimbursement has implications for the consultation-liaison (C-L) psychiatrist. The author reviews results from three health policy studies that indicated 1) degree of reliance on general medical providers for mental health care is not affected by generosity of fee-for-service (FFS) coverage, but is greater in some prepaid health care systems; 2) psychological sickness of depressed outpatients visiting general medical providers is similar across prepaid and FFS systems of care; 3) prepaid care is associated with lower rates of detection of depression and counseling in the general medical sector; 4) depression outcomes in the general medical sector are similar under prepaid or FFS care; 5) quality of care for depressed patients is moderate to low in the general medical sector; and 6) depressed elderly inpatients receive higher quality of psychological care in psychiatric units, but they receive higher quality of physical care in general medical wards. The discussion emphasizes the C-L psychiatrist's role in educating general medical providers, improving outcomes for the sickest patients, and improving psychosocial care in prepaid practices.     

An evaluation of the effectiveness of a consultation-liaison psychiatry service in general practice

OBJECTIVE: This study evaluated the 6-month outcome of patients referred by their general practitioner (GP) to a consultation-liaison (C-L) psychiatry service provided to eight group general practices. METHOD: Over a 12-month period, there were 307 referrals to the C-L psychiatry service of whom 86 consented to take part in an outcome study. Two different control groups were examined comprising patients seen by the same GPs but not referred to the C-L service, who were matched with the C-L referrals on the basis of either demographic characteristics (n = 86) or initial symptomatology (n = 59). Clinical interviews were conducted at recruitment to the outcome study using the Composite International Diagnostic Interview (CIDI), while postal questionnaires were used at both the initial and 6-month assessments. RESULTS: Data reported include DSM-III-R clinical audit and CIDI diagnoses, changes in current symptomatology (SCL-90-R) and changes in global ratings of physical health, emotional health, social relationships and ability to perform everyday duties. Consultation-liaison referrals without symptom-matched controls (n = 27), being patients with higher levels of symptoms initially, were more likely to be referred to other psychiatric services for treatment. They also showed more marked improvement over time on the selected outcome measures. However, there were no significant differences in the patterns of change over time between symptom-matched C-L referrals and their non-referred controls. CONCLUSIONS: The findings from the 6-month outcome study raise doubts about the overall benefit of the current C-L service relative to usual GP care. Improving the quality of psychiatric care in general practice is likely to require a range of interrelated strategies, including C-L psychiatry services, GP education and well-functioning links with public mental health services.     

The future of psychiatric hospitals in Ontario

The purpose of this paper is to review past and present roles and to speculate on the future of the Ontario provincial psychiatric hospitals (PPHs). Currently, and for the very immediate future only, there are 10 PPHs that are owned and operated by the Ministry of Health of Ontario, each serving a specified population ranging from 250,000 to over 3,000,000. In addition to clinical expertise, provincial psychiatric hospitals contribute greatly to teaching and research. Ontario's mental health reform movement has called for a shift of resources to the community and a downsizing of PPHs by 2003. In response to fiscal pressures, in 1996 provincial legislation was passed to establish the Health Services Restructuring Commission (HSRC) as a stand-alone corporation with powers to restructure and reengineer health services in Ontario. The HSRC has to date recommended the closure of 4 PPHs by 1999 and the integration of theses services into other medical facilities. While a rebalancing of the mental health system does need to take place, the fiscally driven haste to close hospitals has created a crisis atmosphere in PPHs for staff and patients. It is also unlikely that the necessary community resources will be in place to buffer these changes. The new restructuring plans not only set unrealistic timelines, they seem to underestimate the importance PPHs have played in teaching, research and the advancement of clinical treatment and rehabilitation of the severely mentally ill. It may be that, in the long run, service integration and divestment/closure of the PPHs will result in better access to services closer to smaller communities and in the destigmatization of the mentally ill, however, without close evaluative monitoring and appropriate leadership, it could also lead to decreased research, training and quality of care.     

The role of psychiatric comorbidity in the prediction of readmission for detoxification

BACKGROUND: The burden of caring for terminal cancer patients has a negative effect on the informal caregivers' quality of life. OBJECTIVES: To investigate the effects of a transmural home care intervention program for terminal cancer patients on the direct caregivers' (the patient's principal informal caregiver) quality of life, compared with standard care programs. The intervention program intended to optimize the cooperation and coordination between the intramural and extramural health care organizations (transmural care). METHODS: Direct caregivers of terminal cancer patients (estimated prognosis of less than 6 months) could be included in this quasi-experimental study. The direct caregivers' quality of life was measured in a multidimensional way 1 week before (T1), 1 week after (T2), and 4 weeks after (T3) the patient's discharge from the hospital (discharge being the starting point of the intervention), then again at 3 months after the patient's death (T4). Factor analyses on the four outcome measures yielded one factor. This was considered the primary outcome measure and was named the Overall Quality of Life Index (OQOLI). RESULTS: Multiple regression analyses showed that the intervention contributed significantly positively to the direct caregivers' OQOLI at T2 (beta=.30; p < .05) and T4 (beta=.28; p < or = .05), compared with standard care. CONCLUSION: Transmural care forms a significantly positive contribution to the OQOLI of direct caregivers of terminal cancer patients 1 week after the patient's discharge from the hospital and 3 months after the patient's death. Good terminal care also appears to be important for direct caregivers as well, with respect to perceived quality of life.     

The future of mental health nurses in liaison psychiatry

This article examines the current status of the mental health nurse in liaison psychiatry. A model for practice is put forward and the need for a cohesive educational framework is argued.     

The psychiatric will: A new mechanism for protecting persons against "psychosis" and psychiatry.

After a brief review of the traditional justifications for and objections to involuntary psychiatric interventions, a new legal mechanism accommodating the interests of both supporters and opponents of such interventions is proposed. Fashioned after the model of the last will and the living will, the psychiatric will provides a mechanism whereby individuals could plan, while rational and sane, for how they wish to be treated in the future, should others consider them to be irrational or insane. Individuals who dread the power of psychosis and desire protection from it by embracing, in case of "need," the use of involuntary psychiatric interventions could execute a psychiatric will in keeping with their beliefs. Individuals who dread the power of psychiatry and desire protection from it by rejecting, regardless of "need," the use of involuntary psychiatric interventions could execute a psychiatric will in keeping with their beliefs. Thus, no one who believes in psychiatric protectionism would be deprived of its alleged benefits, while no one who disbelieves in it would be subjected to its policies and practices against his or her will. (21 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Axis I and II comorbidity in adults with ADHD.

Ongoing debate over the validity of the attention-deficit/hyperactivity disorder (ADHD) construct in adulthood is fueled in part by uncertainty regarding implications of potentially extensive yet incompletely described comorbid Axis I and II psychopathology. Three hundred sixty-three adults ages 18 to 37 completed semistructured clinical interviews; informants were also interviewed, and best estimate diagnoses were obtained. Results were as follows: First, ADHD combined type (ADHD-C) had an excess of externalizing and internalizing Axis I disorders, suggesting a gradient-of-severity relationship between it and ADHD inattentive type (ADHD-I). Second, ADHD-C and ADHD-I did not differ in frequency of Axis II disorders. Third, however, ADHD overall was associated with increased rates of Axis II disorders, compared with rates in non-ADHD control participants, including both Cluster B (primarily borderline personality disorder) and Cluster C disorders. Fourth, ADHD incrementally accounted for clinician-rated global assessment of functioning scores above and beyond comorbid conditions or symptoms on either Axis I or Axis II. Results further inform nosology of ADHD in adults. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Gender differences in psychiatric comorbidity among adolescents with substance use disorders.

The authors examined gender differences in rates of comorbid psychiatric disorders among adolescents with 1 or more psychoactive substance use disorders. Baseline diagnostic data were obtained from 135 adolescents, ages 12 to 19, and their parents-guardians, who participated in a study to develop and efficacy test Integrated Family and Cognitive-Behavioral Therapy. Rates of attention-deficit/hyperactivity disorder and conduct disorder were higher among drug-abusing male adolescents compared with drug-abusing female adolescents. However, high rates of disruptive behavior disorders also characterized drug-abusing female adolescents. Similarly, drug-abusing female adolescents exhibited a higher rate of major depression compared with drug-abusing male adolescents. However, rates of dysthymia, double depression (i.e., major depression and dysthymia), and bipolar disorder were equivalent between genders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychopharmacologic issues in organ transplantation. Part I: Pharmacokinetics in organ failure and psychiatric aspects of immunosuppressants and anti-infectious agents

This article discusses pharmacokinetics and pharmacodynamics during hepatic, renal, and cardiovascular insufficiencies. Hepatic metabolism of psychotropic drugs and of drugs commonly used in transplant patients that have neuropsychiatric side effects is discussed. Neuropsychiatric effects of immunosuppressant agents, including cyclosporine, corticosteroids, azathioprine, OKT3, and FK 506, are reviewed. Certain infections occur more often in immunosuppressed patients; their treatment with antiviral, antifungal, and antibiotic drugs may have neuropsychiatric consequences. Because of altered drug sensitivities and metabolism, drug interactions, and severe medical illness, most drugs are used in reduced doses.     

Past, present, and future of psychiatry: personal reflections

OBJECTIVE: To review the past half century of North American psychiatry from personal experience and to gauge its future prospects. METHODS: An examination of the relevant literature, recollections from a long academic career, and analysis of trends. RESULTS: The pendulum of psychiatric theory continues its swing from its psychological to its biological pole; current economic forces are driving it toward reductionistic biology. The very considerable gains in the psychosocial and neurobiogical knowledge base of our field will ultimately have a potent yield in patient care once the restrictive controls on its application to service provision are lifted. CONCLUSION: The future of research in the sciences basic to psychiatry has never been more promising. How rapidly progress will occur will be a function of the resources society is willing to commit to mental health research. The prognosis for the translation of the new findings to clinical practice will depend on whether professionals can mobilize public support for quality care for the mentally ill.     

Human C-peptide. Part I: Radioimmunoassay

Synthetic human C-peptide bearing a Tyrosine group at its amino end is labelled with 125iodine using chloramin T or hydrogen peroxide and lactoperoxidase. The results are compared applying both methods. Antiserum to synthetic human C-peptide (without Tyrosine) which was partially compared to rabbit albumin, is raised in guinea pigs and goats. Goats show to be superior to guinea pigs concerning antibody production. The so-called "hook effect" phenomenon is observed in setting up the standard curves for the radioimmunoassay. Monotonically decreasing standard curves are obtained on dilution of antiserum with a high antibody titer which was produced by repeated immunization in goats. Free C-peptide and C-peptide bound to antiserum are separated with the anxion exchange resin Amberlite. Using this separation technique we excluded unspecific binding of labelled C-peptide to protein fractions in serum of diabetics. The sensitivity of our radioimmunoassay is approx. 0.3 ng C-peptide/ml serum. Intra- and interassay variability are below 10%. Human proinsulin is the only substance found to crossreact with the antiserum.     

Physical and mental comorbidity of substance use disorders in psychiatric consultations. European Consultation-Liaison Workgroup

Comorbidity of substance use disorders with physical and mental disorders was investigated among 1249 consecutive psychiatric consultation patients admitted to six general hospitals in Finland. Of the patients 354 (28%) were diagnosed with substance use disorders (ICD-10), of which 22% were due to use of at least two different types of psychoactive substances. Alcohol dependence (117/226) in male patients and acute drug intoxication (49/128) at a similar rate as alcohol dependence (44/128) in female patients were the most common clinical conditions. With few exceptions, all substance use disorders were comorbid and in 63% of affected patients comprised a "triple diagnosis" (i.e., physical, mental, and substance use diagnoses concurrently). Poisonings and personality disorders in both sexes, digestive system diseases in men, and injuries in women were related to substance use disorders. Conclusions for service provision were: (1) the high level of co-occurrence of physical and mental disorders with substance use disorders calls for comprehensive, multi-disciplinary assessment of any substance use problems ascertained in psychiatric consultations; (2) poisoning with substance use involvement and mental comorbidity was the most common combined clinical condition justifying provision of addiction psychiatric emergency consultations in general hospitals; (3) polydrug use indicating severe problems and complex treatment needs should be identified; and (4) psychiatric referrals of patients with physical alcohol-related disorders should be ensured in general hospitals.