Detection and treatment of psychiatric illness in a general medical ward: a modified cost-benefit analysis

This article describes a prospective, randomized, controlled trial of screening and treatment for psychiatric disorder in medical in-patients. The study has assessed whether increased recognition of psychiatric disorder among medical in-patients improves clinical outcome and reduces the costs of care, and whether routine involvement of a psychiatrist in the assessment and care of medical in-patients with probable psychiatric disorder is superior to the efforts of the physicians alone. A total of 218 medical in-patients who scored over the screening threshold for psychiatric disorder on the General Health Questionnaire were randomly allocated to one of two intervention groups or a control group. Six months later their mental health, subjective health status, quality of life, and costs of care was reassessed. Mental health and quality of life at 6 months were similar in the two intervention groups and the control group. Patients whose physicians were told the results of the screening test had lower costs for subsequent admissions, but this was probably due to differences between the groups in terms of employment status. Treatments recommended by psychiatrists broke down when patients were discharged home, leading to inadequate treatment of psychiatric disorders. We have not been able to show that routine screening for psychiatric disorder produces any benefit, either in better outcome for patients or reduced costs for the NHS. Further research should: consider examining a more homogeneous group in terms of costs of care; screen only for disorders likely to respond to a specific treatment; and ensure that treatment recommendations are carried out.     

Attitudes of neurologists, psychiatrists, and psychotherapists towards predictive testing for Huntington's disease in Germany

Predictive testing for Huntington's disease (HD) in Germany is performed by genetic counsellors, neurologists, psychiatrists, and psychotherapists. In order to evaluate the attitudes of neurologists, psychiatrists, and psychotherapists in Germany towards predictive testing for HD, a postal questionnaire was sent to this group. Two German Bundesl?nder were chosen, Baden Württemberg (BW) and Niedersachsen (NS). Of 469 persons interviewed the response rate was 32.6%. The questionnaire consisted of 17 items assessing sociodemographic data, acquaintance with HD patients, lay organisations, attitudes towards genetic counselling, presymptomatic and prenatal DNA testing, and reproduction of persons at risk for HD. More than 70% of the subjects were well informed about predictive DNA testing but knowledge about the details of the test procedure, especially the World Federation of Neurology (WFN) and International Huntington Association (IHA)1 recommendations, was quite low (11.8%). Nevertheless, the majority would recommend predictive testing for HD although they anticipated problems for the probands. The majority of our respondents favoured psychological test and post-test counselling for those tested. Concerning reproduction, most subjects favoured prenatal testing or that persons at risk should refrain from having children. We found that the opinions of practitioners and at risk persons differed with respect to the predictive DNA test and, particularly, to prenatal testing. Therefore the testing procedure could be improved if practitioners were better informed about the DNA test in general and about the attitudes and wishes of their patients.     

Breast neoplasms: information in question(s). A survey of patients and physicians at a cancer treatment center

OBJECTIVE: The aim of this study was to know the wishes of our patients for information and to compare them with the point of view of our colleagues in a cancer center. METHODS: We gave 100 consecutive new patients with breast cancer a questionnaire about their needs. The same questionnaire was given in duplicate to all our colleagues in the cancer center (n = 53) asking: 1) their own needs of information if they had breast cancer 2) how they thought the patients would answer. RESULTS: Seventy-five percent of the patients and 81% of the doctors returned the questionnaire (28 were men and 15 women; 81% were involved in the management of breast cancer). On one hand, concerning information about the disease and about the treatment, there was no difference between the needs expressed by patients of doctors (as patients). As expected, the two groups wanted to be well informed. On the other hand, there was always a statistically significant difference between the needs expressed by patients and the opinion of doctors who systematically underestimated them. Concerning information to the family, 21% of doctors and only 4% of patients didn't want any information to be given to their family. Interestingly, 67% of the patients thought the decision had to be taken together with the doctor and 56% of the doctors (as patients) wished the decision to be taken by the doctor. CONCLUSION: Patients and physicians if they were patients, expressed the same high level need of information, but the patients needs seemed underestimated by the majority of doctors.     

Pathways to mental health services among inhabitants of a Mexican village

Critical Incident Monitoring (CIM) as an instrument of quality assurance (QA) has received increasing attention in recent years. The present study was developed to explore a potential role for CIM in QA for clinical psychiatry. A questionnaire was sent to psychiatrists and requested retrospective reporting of clinical incidents, and a pilot study of an inpatient-based incident reporting system was performed. All Fellows of the Royal Australian and New Zealand College of Psychiatry (RANZCP) were sent a questionnaire. Eight psychiatric inpatient services were invited to participate in the pilot study. The returns of the questionnaires were aggregated and analysed to reveal a relatively small number of separate incident types, with little difference between the 'adverse outcome' and 'near-miss' categories. Similar results were found with the pilot study. It was concluded that the development of a unified incident reporting system for use by psychiatric clinicians and psychiatric services may add usefully to existing quality improvement processes.     

Attitudes of psychiatrists toward elderly patients

A group of 179 psychiatrists responded to a questionnaire requesting their opinions concerning four clinical vignettes. Analysis of their responses indicated that these psychiatrists, at a highly statistically significant level, regarded older patients as less ideal for their practices than younger patients with identical symptoms. The respondents viewed the older patients as having a poorer prognosis, and their treatment plans for them were less likely to emphasize psychotherapy. In general, there was a negative correlation between the age of the respondent psychiatrists and their estimate of the "idealness" of and favorable prognosis for older patients.     

Black psychiatric patients' reactions to the cultural mistrust inventory

This pilot study examined African-American psychiatric patients' reactions to the Cultural Mistrust Inventory, a measure of blacks' mistrust of white society. Twenty-two black psychiatric patients were screened for the Culturally-Sensitive Diagnostic Interview Research Project. All patients were debriefed after the screening interview including queries about their reactions to the experience, whether they would be willing to participate in the next interview, and their reasons for participating or not. Patients' responses were recorded verbatim and were categorized in terms of their valence (positive, neutral, or negative) and affectivity (yes or no) by independent raters. Agreement between raters in terms of the valence of patients' reactions was very good, but it was poor to fair in terms of affectivity ratings. The majority of these black patients' responses were positive and nonaffective. Administration of the Cultural Mistrust Inventory to black psychiatric patients does not cause negative emotional reactions.     

Understanding of informed consent by elderly patients

Fifty patients, aged 60 years or more, who had been admitted to a hematology ward for more than 1 month, were studied in regard to their understanding of informed consent. The doctors informed 74% of their patients about the disease for which they were being treated. The rate of informing patients remained low in those with advanced age or with malignant tumors. However, only 42% of the patients realized that they had been informed of their diagnosis and clinical condition. The comprehension rate remained low at 43.2% even in patients who were informed by their doctors. While 60% of patients declared that they understood what the doctors described, only 36% could write something about the name or the state of their disease. Even among the patients who could understand the doctor's explanation, the comprehension rate was 43.3%. Sixty-six percent of patients demonstrated their wish to have a correct explanation of their diagnosis, 36% of patients wanted to be treated according to their own wishes, and 48% of patients left the decisions regarding their treatment to the doctors.     

The effects of contextual information and gender on the prediction of hypnotic susceptibility.

Council, Kirsch, and Hafner (1986) obtained empirical support for the hypothesis that significant correlations between questionnaire measures of absorption and hypnotic susceptibility are an artifact of subjects' beliefs about their own hypnotizability. We tested this hypothesis in a two-session experiment. During Session 1, subjects completed questionnaire measures of absorption, mystical experience, daydreaming frequency, and paranormal beliefs. During Session 2, subjects were tested for hypnotic susceptibility. Subjects were also exposed to one of three information manipulations: They were told about hypnotic testing either before or after filling out the questionnaires or were not told about hypnotic testing. The information manipulation moderated the prediction of susceptibility by the questionnaire measures for women, but not for men. For women, scores on the absorption questionnaire predicted susceptibility only when subjects were informed about hypnotic testing. In the told-after condition, this effect generalized to all of the remaining questionnaire measures. For men, none of the questionnaires was a reliable predictor of susceptibility. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Beliefs about the helpfulness of interventions for mental disorders: a comparison of general practitioners, psychiatrists and clinical psychologists

OBJECTIVE: The aim of this study was to assess health professionals' beliefs about the helpfulness of a broad range of possible interventions for mental disorders. METHOD: The study involved a postal survey of 872 general practitioners (GPs), 1128 psychiatrists and 454 clinical psychologists. These health practitioners were presented with a vignette describing either a person with schizophrenia or one with depression. The vignettes were taken from an earlier survey of the general public. Respondents were asked to rate the likely helpfulness of various types of professional and non-professional help and of pharmacological and non-pharmacological interventions. RESULTS: Two-thirds or more of each profession agreed that the person with schizophrenia would be helped by GPs, psychiatrists, clinical psychologists, antipsychotic agents and admission to a psychiatric ward. Similarly, two-thirds agreed that the person with depression would be helped by GPs, psychiatrists, clinical psychologists, antidepressants, counselling and cognitive-behavioural therapy. However, there were also areas of disagreement. Psychiatrists were less likely than GPs and clinical psychologists to rate psychological and lifestyle interventions as helpful, while clinical psychologists were less likely to rate specifically medical interventions as helpful. Younger members of the professional groups and female members (who also tended to be younger) tended to rate a wider range of interventions for each disorder as likely to be helpful. CONCLUSIONS: Despite areas of broad agreement about treatment, health practitioners were more likely to endorse the interventions associated with their own profession. However, younger members of each profession tended take a broader view. If these age differences represent a cohort effect, health professionals may in the future show greater acceptance of the helpfulness of interventions offered outside their profession. These conclusions are limited by the methodology of the survey, which involved a questionnaire designed for the public rather than professionals.     

Psychiatric diagnosis and intervention in older and younger patients in a primary care clinic: effect of a screening and diagnostic instrument

OBJECTIVES: To determine whether patient age is associated with psychiatric diagnosis or provider intervention in a busy primary care clinic, and, if so, whether a screening and diagnostic tool, the PRIME-MD, modifies age-related differences. DESIGN, SETTING, AND PARTICIPANTS: PRIME-MD use, psychiatric diagnosis, and provider interventions for psychiatric conditions were recorded for eligible patients attending a Veterans Affairs Medical Center primary care clinic. Data from 952 younger (<65 years) and 1135 older patients (> or =65 years) were analyzed to determine whether there were age-related differences in diagnosis/intervention and if use of the PRIME-MD modified these differences. INTERVENTION: Implementation of the PRIME-MD, a two-step instrument consisting of a self-administered patient questionnaire and a provider-administered structured diagnostic interview. MEASUREMENTS: Outcome measures were rates of (1) PRIME-MD use, (2) overall psychiatric diagnosis, (3) new psychiatric diagnosis, and (4) provider intervention for psychiatric conditions. RESULTS: There was no association between patient age and PRIME-MD use. Older patients were less likely to receive a psychiatric diagnosis in analyses that adjusted for "highly positive" screening questionnaires (OR = .45; P<.001). Older patients were also less likely to receive an intervention for a psychiatric condition in analyses that adjusted for whether a psychiatric diagnosis (OR = .62, P = .015) or a new psychiatric diagnosis (OR = .36, P<.001) was made during the study visit. The PRIME-MD increased rates of diagnosis and intervention but did not alter age-related disparities. CONCLUSIONS: Decreased rates of psychiatric diagnosis and intervention in older primary care patients are of concern. Implementing the PRIME-MD will likely increase rates of diagnosis and intervention but will need to be accompanied by additional measures to eliminate age-related disparities.     

Evaluating and overcoming barriers to taking abuse histories.

Psychologists are frequently faced with issues of whether, when, and how to ask clients if they have been abused. Despite the demonstrated relationship between child abuse and adult psychopathology, researchers report that many clinicians still do not routinely inquire about abuse. A questionnaire completed by 63 psychologists and 51 psychiatrists in New Zealand revealed that factors related to reluctance to ask about abuse include the following: more pressing issues, fear of disturbing clients, a diagnosis of schizophrenia, biological etiology beliefs, and fear of inducing "false memories." Significant differences were found between psychologists and psychiatrists on some of these factors. Practice guidelines for enhancing the frequency and efficacy of abuse inquiry are presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prevalence of psychoactive substance use among psychiatric in-patients in Harare, Zimbabwe

OBJECTIVE: To determine the prevalence of psychoactive substance use among psychiatric in-patients in Harare. DESIGN: A cross sectional study that was conducted in 1994. SETTING: Harare Central Hospital Psychiatric Unit. SUBJECTS: A total of 194 consecutively admitted patients to Harare Central Hospital Psychiatric Unit, aged from 16 to 55 years with a mean (SD) age of 33.5 (11.4) years. MAIN OUTCOME MEASURES: The psychiatric diagnoses were made according to the ICD10 diagnostic criteria, while the substance abuse was evaluated by the modified WHO AUDIT core questionnaire, which was translated into the Shona language. RESULTS: The point prevalence rate of psychoactive substance abuse among the psychiatric in-patients were alcohol 28.4% (95% CI = 22.1, 34.7), tobacco 27.6% (95% CI = 18.7, 36.5) and cannabis 14.3% (95% CI = 7.4, 21.2). CONCLUSION: The data have provided scientific evidence on the moderate prevalence and pattern of substance abuse among psychiatric patients in Zimbabwe.     

Clinical risk management of the rapid-cycling bipolar patient

Important clinical-legal issues surround the management of patients with rapid-cycling bipolar disorder (RCBD). An increased risk of liability exposure may exist for improper diagnosis and treatment, lack of informed consent, inadequate assessment of the risk of violence toward self and others, and failure to monitor the patient. Practice guidelines may facilitate defensive practices by psychiatrists, which can increase the risk of liability. Clinical risk management combines professional expertise and knowledge of the patient with an understanding of the legal issues governing clinical practice to provide good care to patients and only secondarily to limit legal liability. A working understanding of the legal issues surrounding patient care in general and the RCBD patient in particular should provide more comfort and wider latitude in helping these difficult-to-treat patients.     

From reassurance to irrelevance: Adolescent psychology and homosexuality in America.

American psychology by the 1920s contained a greater capacity for viewing some homosexual experiences as normal than most current historical literature suggests. Developmental psychologists agreed with psychiatrists that adult homosexuality was pathological, but they also agreed that adolescent sexual development included a homosexual phase. Until the late 1960s, developmental texts reassured parents and teachers that homosexual behavior among adolescents was transitory and quite normal. The psychiatric view of homosexuality as pathology came under attack after the middle of the century and eventually was abandoned. The developmental concern with a transitory homosexual phase disappeared gradually. This trend in psychology suggests underlying social and cultural changes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

On pseudoscience in science, logic in remission, and psychiatric diagnosis: A critique of Rosenhan's "On being sane in insane places".

Argues that D. L. Rosenhan's (see record 1973-21600-001) report on normal persons who posed as psychiatric patients is pseudoscience presented as science. Just as his pseudopatients were diagnosed at discharge as "schizophrenia in remission," so a careful examination of this study's methods, results, and conclusion leads to a diagnosis of "logic in remission." Rosenhan's study proves that pseudopatients are not detected by psychiatrists as having simulated signs of mental illness. This rather unremarkable finding is not relevant to the real problems of the reliability and validity of psychiatric diagnosis and only serves to obscure them. A correct interpretation of these data contradicts the conclusions that were drawn. In the setting of a psychiatric hospital, psychiatrists seem remarkably able to distinguish the "sane" from the "insane." (19 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

1997 IPA/Bayer Research Awards in Psychogeriatrics. The wish to die in very old persons near the end of life: a psychiatric problem? Results from the Berlin Aging Study

The wish to die in elderly persons is currently under debate. Experts are questioning whether it is natural for these individuals to show a wish to die, whether the right to eventually kill oneself should be respected, or whether suicidal intentions in old age are expressions of mental disorders that need intensive, professional care. A representative community sample of 516 persons aged 70 to 105 was extensively investigated by psychiatrists using the structured interview Geriatric Mental State Examination-Version A (GMS-A) and several self-rating and observer-rating scales. Diagnoses were made according to DSM-III-R criteria and by clinical judgment. The goal of the study was to find examples of "pathology-free wishes to kill oneself." A total of 115 out of 516 very old (70 to 105 years) persons, which represents 21.1% of the community population, said at the time of investigation that they wanted to die or felt life was not worth living (Hamilton Depression Rating Scale [HAMD] score 1, 2, or 3). Forty-three very old persons (6% of the community population) had the wish to be dead according to the HAMD or the GMS-A, and 11 persons (2% of the community population) had suicidal intentions. Depending on the intensity of suicidality, 80% to 100% were clinically diagnosed as having psychiatric disorders and half to three quarters showed symptoms fulfilling the criteria of at least one specified psychiatric diagnosis. Acute suicidal intentions were in all cases associated with at least one specified diagnosis according to DSM-III-R. Thirteen persons out of 54 who actually wanted to die (GMS-A category 4, 5, 6 or HAMD category 2, 3) did not fulfill criteria for specified diagnoses. Seven individuals showed scores in self-rating and observer-rating scales that speak for mental disorders apart from pure suicidality. Six remaining persons are described in greater detail in short case vignettes. They showed either mild but chronic psychiatric disorders, fluctuating courses, or an atypical phenomenology of psychiatric disorders. The results of this study strongly suggest that the wish to be dead in the very old is most probable, and suicidal intentions are definitely associated with psychiatric disorders.     

Do clinical and formal assessments of the capacity of patients in the intensive care unit to make decisions agree?

BACKGROUND: The complex environment and technology of intensive care unit (ICU) care may impair the ability of patients to participate in medical decision making or give informed consent. We studied the agreement of the intuitive assessments of residents and nurses of ICU patients' cognition, judgment, and decision-making capacity, and whether those assessments agreed with abbreviated formal mental status testing. METHODS: Using a prospective survey case study, we assessed 200 English-speaking patients within 24 hours of their ICU admission. Formal assessment of cognition, judgment, and insight was performed by a research assistant. We obtained independent intuitive ratings by nurses and residents of patient cognition, judgment, and ability to participate in medical decision making or give informed consent. RESULTS: Residents' and nurses' assessment of cognition and judgment showed a high degree of agreement with weighted ks of greater than 0.76. Assessments of cognition by residents and nurses agreed with Folstein Mini-Mental State Examination in 70% and 73.6% of cases, respectively. Forty percent of the population had an unimpaired Mini-Mental State Examination score of greater than 23, and an additional 12% of the subjects were mildly impaired with scores of 20 to 23. When asked whether they would approach patient or family for consent for an invasive procedure, nurses and physicians said they would request informed consent from 66% and 62% of the patients, respectively. CONCLUSIONS: Residents and nurses caring for patients newly admitted to the ICU agree in their assessment of cognition, judgment, and capacity to participate in medical decision making, and are not unduly influenced by ventilator status. Their assessments correlate highly with abbreviated formal mental status testing.     

Sharing care: the psychiatrist in the family physician's office

OBJECTIVE: One way of strengthening ties between primary care providers and psychiatrists is for a psychiatrist to visit a primary care practice on a regular basis to see and discuss patients and to provide educational input and advice for family physicians. This paper reviews the experiences of a program in Hamilton, Ontario that brings psychiatrists and counsellors into the offices of 88 local family physicians in 36 practices. METHOD: Data are presented based on the activities of psychiatrists working in 13 practices over a 2-year period. Data were gathered from forms routinely completed by family physicians when making a referral and by psychiatrists whenever they saw a new case. An annual satisfaction questionnaire for all providers participating in the program was also used to gather information. RESULTS: Over a 2-year period, 1021 patients were seen in consultation by one full-time equivalent psychiatrist. The average duration of a consultation was 51 minutes, and a family member was present for 12% of the visits. Twenty-one percent of the patients were seen for at least one follow-up visit, 75% of which were prearranged. In addition, 1515 cases were discussed during these visits without the patient being seen. All participants had a high satisfaction rating for their involvement with the project. CONCLUSIONS: Benefits of this approach include increased accessibility to psychiatric consultation, enhanced continuity of care, support for family physicians, and improved communication between psychiatrists and family physicians. This model, which has great potential for innovative approaches to continuing education and resident placements, demands new skills of participating psychiatrists.     

Coping and the decision to hospitalize in emergency psychiatry

This study was done to clarify whether and in what way a patient's coping repertoire can be linked to the disposition decision in a psychiatric emergency service. For 1 year, all consultations (N = 1439) of a psychiatric emergency service were documented in a detailed questionnaire covering sociodemographic and diagnostic data as well as information about the disposition decision. Depending on disposition, three groups were identified: outpatients (N = 530), inpatients (N = 481), and a nonintervention group (N = 428). In addition, over a 5-month period, patients were requested to fill in the "Bernese Coping Modes" questionnaire. Thus, a sample of 28 patients undergoing outpatient crisis intervention and 28 patients referred to inpatient treatment was obtained. Statistical analysis included Chi square-test, t-test, Mann-Whitney U-test, and logistic regression analysis. Assessment of coping repertoire contributed more than the diagnosis to the decision to hospitalize. Outpatients have a larger coping repertoire (t = 3.48, p = 0.001) than inpatients and show higher values in "acceptance-stoicism," "dissimulation," "tackling," "giving meaning," "altruism," "optimism," and "relativizing." Logistic regression revealed relativizing, altruism, and optimism as being most important. Self-referral to emergency psychiatry was also correlated with outpatient treatment. Other criteria such as being without work, living alone, history of previous hospitalization, and the diagnosis of a psychotic or mood disorder were significantly correlated with referral to inpatient treatment. More attention should be paid to patients' coping repertoires in emergency services when deciding about the need for inpatient treatment.