Physical illness and the psychiatric patient

The significance and seriousness of physical illness in mentally ill patients are often not appreciated by those responsible for the immediate care of these patients. This study highlights the nature and prevalence of physical illnesses in a large group of psychiatrically ill patients.     

Aspects of perinatal psychiatric illness

BACKGROUND: In view of the current changes in the National Health Service, it was considered an opportune time to review the literature on perinatal psychiatric illness. METHOD: A systematic review was undertaken of relevant articles on MEDLINE, ClinPsych and Excerpta Medica Psychiatry. RESULTS: Sixty-eight articles were used in the review. CONCLUSIONS: Developments in the field of perinatal psychiatry include a greater understanding of the nosology and aetiology of the conditions, the effect of maternal illness on the child, as well as transcultural factors. The perspective of the individual sufferer has been somewhat ignored. New treatments with both pharmacotherapy and hormones are emerging, but perhaps the greatest current challenge is to adapt our management strategies to community care.     

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.     

Iron overload is a risk factor for zygomycosis

Well-recognized risk factors for zygomycosis include diabetic ketoacidosis, immunocompromise, and deferoxamine therapy for iron or aluminum overload, usually in patients undergoing kidney dialysis. We report a case of fatal nasal-orbital-cerebral zygomycosis in an 82-year-old man with known myelodysplasia and well-controlled diabetes. He was not receiving deferoxamine. Despite radical surgery and amphotericin B therapy, he died; primary hemochromatosis with gross iron overload was found post mortem. Experimental evidence suggests iron overload without deferoxamine therapy may be a risk factor for zygomycosis; the findings in this case would support this hypothesis.     

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)     

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.     

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.     

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.     

Iron overload in the rat pancreas following portacaval shunting and dietary iron supplementation

Reproduction of pancreatic iron overload in an animal model has been difficult to achieve primarily because of the first-pass extraction of iron by the liver. We hypothesized that portacaval shunting would avoid this hepatic phenomenon and increase pancreatic iron deposition. An end-to-side portacaval shunt was surgically created in male Sprague-Dawley rats, and they were subsequently fed a carbonyl iron-supplemented diet for 17 weeks. This resulted in marked iron accumulation in the pancreas (1621 +/- 188 micrograms/g) compared to minimal deposition in sham-operated rats fed the same diet (138 +/- 53 micrograms/g). Iron deposition in the acinar and centroacinar cells was confirmed histologically by Gomori staining, as well as by ultrastructural examination. Iron overloading was associated with enhanced oxidative stress evidenced by a twofold increase in the levels of glutathione disulfide and thiobarbituric acid-reactive substances. Also, adducts of proteins with malondialdehyde and 4-hydroxynonenal were demonstrated in acinar and ductal cells. Other apparent consequences of iron overload were a 50% reduction in pancreatic amylase content and a decrease in pancreatic protein concentration. These hypotrophic changes were associated with a reduced mass of zymogen granules in the acinar cells noted histologically. Our results show that a combination of portacaval shunting and carbonyl iron feeding achieve pancreatic iron overload and support the role of oxidative stress in the pathogenesis of iron-induced damage in the pancreas.     

Use of hospital services by AIDS patients with psychiatric illness

The purpose of this study was to assess the effect of psychiatric illness on length of stay and patterns of admission among AIDS patients hospitalized for medical illnesses. Medical records were abstracted for AIDS patients admitted to hospitals in Washington State from 1990 through 1992. Psychiatric comorbidity was defined by the presence of an International Classification of Disease-9 code reflecting psychiatric illness. Medical morbidity was addressed using CD4 count and AIDS-defining illnesses as markers of disease severity. Of 2834 admissions, 15% included one or more psychiatric diagnoses. Psychiatric illness (F 39.1; df 1,2830; p < 0.001) and discharge disposition (F 81.2; df 2,2830; p < 0.001) contributed significantly to the model, explaining increased length of stay (F 67.2; df 3,2830; p < 0.001). Future research needs to address the possible etiology of psychiatric comorbidity's contribution to length of stay and the effect on quality and cost of care.     

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.     

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.     

The psychiatric will: Is the cure worse than the illness?

Points out legal difficulties concerning T. S. Szasz's (see record 1983-05532-001) proposal of a "psychiatric will," similar to a "living will," to resolve the conflict between involuntary hospitalization vs the right to treatment of individuals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relation between psychiatric disorder and abnormal illness behaviour in patients undergoing operations for cervical discectomy

The role of nitric oxide (NO) in pathophysiology of urethral obstruction in male guinea pig was investigated by using nicotinamide adenine dinucleotide phosphate-diaphorase (NADPH-d) histochemistry. In normal and sham-operated control animals, NADPH-d reactivity in the ventral horn motoneurons at L5-L6 and S1-S2 segments of spinal cord was barely detectable or virtually absent. In animals receiving urethral ligation and killed at 6 h after operation, NADPH-d reactivity in the ventral horn motoneurons was comparable to that of control animals. At 12 h, NADPH-d reactivity in the same cells began evident and was markedly enhanced in animals killed at 24 and 48 h. In order to verify whether the increased NADPH-d reactivity was linked to neuronal death, some sections of the lumbosacral spinal cord from urethral obstructed animals were stained in Nissl staining. There was no sign of cell death or atrophy of the ventral horn neurons. Present results suggest the plasticity of NADPH-d in ventral horn neurons which is readily upregulated by urethral ligation. The enhanced NADPH-d reactivity would imply increased nitric oxide synthase (NOS) activity and consequently generation of higher levels of NO in ventral horn neurons. Such alteration maybe involved in distension-induced urethral relaxation in the external urethral sphincter following urethral ligation.     

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.     

Effects of disclosure of traumatic events on illness behavior among psychiatric prison inmates.

To assess the health effects of writing about traumatic events in a clinical population, 98 psychiatric prison inmates were randomly assigned to 1 of 3 conditions in which they were asked to write about their deepest thoughts and feelings surrounding upsetting experiences (trauma writing condition), write about trivial topics (trivial writing control), or go about their daily routine without writing (no-writing control). Both writing groups wrote for 20 min per day for 3 consecutive days. Participants in the trauma condition reported experiencing more physical symptoms subsequent to the intervention relative to those in the other conditions. Despite this, controlling for prewriting infirmary visits, sex offenders in the trauma writing condition decreased their postwriting infirmary visits. These results are congruent with predictions based on stigmatization and inhibition. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effect of a split in WAIS-R VIQ and PIQ scores on patients with cognitive impairment and psychiatric illness

To determine the most effective treatment for acrodermatitis chronica atrophicans, several clinical trials were undertaken in recent years to evaluate whether a 2-week course of ceftriaxone would be superior to oral antibiotics. Of the 46 patients suffering from acrodermatitis chronica atrophicans, 14 were treated with ceftriaxone 2g for 15 days. The remaining patients received either oral penicillin V 1.5 million IU t.i.d. or doxycycline 100 mg b.i.d. for 20 to 30 days. Patients were followed up for at least 1 year. Of the 14 ceftriaxone-treated patients four showed incomplete regression of the inflammatory skin changes after 6 to 12 months. Two out of five patients who were monitored for Borrelia burgdorferi DNA excretion were still positive after 12 months as compared to none of six patients who were treated orally for 20-30 days. Six out of 11 patients treated orally for only 20 days needed retreatment after 6 months because of continuing skin manifestations, neuropathy or arthralgia. A 30-day duration of treatment with oral antibiotics and not the chosen antibiotic is crucial for curing acrodermatitis chronica atrophicans. The duration of treatment with ceftriaxone needed for eradication of Borrelia in acrodermatitis chronica atrophicans has yet to be determined in future studies.