Is there a need for admission and discharge cognitive screening for the medically ill?

The Cognitive Capacity Screening Examination, developed to detect cognitive deficits as possible manifestations of diffuse organic mental syndromes, was administered on admission and at discharge to 106 patients on a medical ward of a general hospital (mean age, 56 years). Thirty-three percent of the patients showed diminished cognitive capacity at admission, of which 16% were undetected by the house staff. Restudy at discharge revealed that 28% of the sample continued to have diminished cognitive capacity. This study documents the incidence of cognitive deficits, highlights the need for early detection, and offers practical considerations for discharge procedures.     

Utilization pattern of a Canadian psychiatric consultation service

The authors reviewed 255 psychiatric consultations in a Canadian teaching general hospital over a one-year period. The majority of the patients were referred from the medical and surgical services. The three most commonly stated reasons for referral were either parasuicidal behavior, depression, or psychological conflicts affecting physical illness. The three most common primary psychiatric diagnoses were: affective disorders, organic brain syndromes, and transient situational disturbances. The factors influencing compliance among the patients referred for psychiatric ambulatory treatment were studied. Compliance was defined as attendance at the first appointment. Of the 42.8% of the patients referred for ambulatory psychiatric treatment, 54% complied.     

The house officer and the dying patient: Attitudes, experiences, and needs

A survey of house staff who care for dying patients was conducted at a large medical center and demonstrated that house officers are aware of their discomfort in dealing with dying patients and their families but believe they do not avoid them. They strongly agreed with the use of the “no code” designation and believed the quality of life was the most important factor in making that decision. The house officer who has concerns about a dying patient is most likely to talk with another house officer. The survey highlights the needs of house staff for experienced resource people and informal programs dealing with the care of dying patients.     

Psychiatric consultations in a general hospital. A report on 1,000 referrals.

1,000 medical and surgical inpatients referred for psychiatric conSULTATION SHOWED CONCURRENT PHYSICAL AND PSYCHIATRIC DISORDER IN 68.2% of cases. This is in accordance with epidemiological findings that these two types of morbidity have a positive association and coexist in 20-50% of patients. Depression was the commonest psychiatric disorder in all classes of organic disease and accounted for 53% of all psychiatric diagnoses. Organic brain syndromes, acute and chronic constituted 18% of referrals. Almost twice as many women as men were referred despite their nearly equal distribution in hospital population. One-third of the females had no positive medical diagnosis compared to one-fifth of the men. Alcoholism was a major problem in 8.9% of referrals. 7.8% of patients were referred following suicidal attempt. Of the 50 patients with cancer. 66% had depression. Too few medical patients with psychiatric complications are referred and adequately treated. Greater emphasis on teaching psychiatric syndromes is called for. Psychiatric consultation-liaison services offer the most direct form of collaboration between psychiatry and medicine in the interests of comprehensive patient care.     

Psychiatric disorders and the need for mental health services among a sample of orthopedic inpatients.

This report concerns psychiatric disorders and the need for mental health services among patients admitted to a general orthopedic surgery service. The planning of mental health services for medical and surgical inpatients in terms of current community mental health concepts is discussed.It has been observed that patients being treated for medical or surgical conditions have a higher than expected incidence of psychiatric disorders.^1–6 Previous studies of inpatients with orthopedic or other surgical conditions report a wide range (19%–86%) of psychiatric disorders depending upon the diagnostic criteria employed. In spite of the documented need for mental health services among such patients, primary physicians are often reluctant to request psychiatric consultation, and the psychiatrist is usually consulted only when a patient presents a difficult management or diagnostic problem.^3,7,8 Thus, many other medical or surgical patients could benefit from mental health consultation if their needs could be identified.In recent years, psychiatrists have become more involved in the functioning of general medical services, with consideration being given to the application of the principles of community mental health to the consultation services.^2,4,9–12 Psychiatrists have participated in indirect consultation through the medical and nursing staff in addition to providing direct consultation within medical and surgical settings. In planning this type of consultation service, more information is needed about the kinds of mental health problems experienced by medical and surgical patients.     

Psychiatric factors in the management of long-term hyperalimentation patients

Most patients receiving chronic IVH therapy adjust well, not only to their treatment, but also to their underlying illness. Depression, organic mental syndromes, and encapsulated delusions occur with sufficient frequency to educate staff, patients, and families as to their possible occurrence. Discussing their possible development before they appear reduces anxiety and makes the patient feel less alien. Advance knowledge makes management easier and permits families to discuss problems before they become major sources of conflict. Multidisciplinary hyperalimentation teams of medical, surgical, and psychiatric physicians, psychiatric and specially trained TPN nurses, social workers, pharmacists and dietitians are useful in providing a comprehensive program for long-term hyperalimentation patients. The elements of a TPN program should include: 1) medical services available 24 hours a day; 2) a comprehensive educational program for staff, patients, and family members; 3) psychiatric support on both a routine and an as-needed basis; 4) patient participation in treatment planning; 5) easy access to needed supplies; and 6) and assistance with financial planning.     

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.     

A study of anxiety/depressive symptoms of medical students, house staff, and their spouses/partners

Symptoms of anxiety/depression and suicidal ideation were studied in medical students, house staff, and their spouses/partners in a large midwestern school by means of an anonymous questionnaire. A total of 634 medical students and 227 house staff completed the questionnaire. A significantly higher proportion of female trainees than male trainees reported symptoms of anxiety/depression (41% compared with 27%). This difference between men and women was most marked during residency training. The proportion of men reporting anxiety/depressive symptoms declined between medical school (33%) and residency (10%). No such decline occurred with women (medical students 42%, residents 37%).     

Admissions to a South African general hospital psychiatric unit

In a study of adminssions to the psychiatric unit of a general hospital from December 1, 1977, to November 30, 1978, data obtained from all 478 admitted patients were analyzed; the most prevalent condition was found to be the neuroses, followed by organic brain syndromes. Most patients admitted fell into the 19–39 age group, with a preponderance of male admissions between the ages of 6–39, but more admissions of females above 40. A significant difference in the occurrence of conditions between the sexes was noted: the most prevalent condition for males between the ages of 6–39 years was schizophrenia, while more females suffered from the neuroses. Males 40 years and older presented predominantly with organic brain syndromes; females in that age group presented predominantly with affective psychoses. The average length of stay for both sexes was eight days. Schizophrenia required the longest hospital stay, an average of 11 days. Seventy-eight patients (16.3%) were admitted more than once during the period of study. Conditions commonly associated with readmission were affective psychoses and schizophrenia. The role of the general hospital psychiatric unit and its advantages and shortcomings are discussed.     

Spontaneous brain hemorrhage

Spontaneous brain hemorrhage accounts for about 10% of all strokes and is fatal in about 50% of the cases. Its incidence, in contrast to other types of strokes, has not declined. Hypertension accounts for about half of these hemorrhages; the rest are due to tumors, aneurysms and vascular malformations, inflammatory and degenerative vasculopathies and hematologic and iatrogenic disorders of coagulation. In some patients no cause is ever found. Hypertensive brain hemorrhage occurs in the deep gray nuclei of the hemispheres, the cerebellum, and the pons and results in specific clinical syndromes depending on the location. Computerized tomography has revolutionized the diagnosis of brain hemorrhage and is resulting in the development of rational criteria for medical and surgical management of these lesions. Intensive medical therapy guided by clinical status and continuous monitoring of ICP may improve outcome. Surgical removal of the hematoma is indicated in lobar and putaminal hemorrhages when the patient is deteriorating in spite of vigorous medical therapy. In addition most large (greater than 3 cm) cerebellar hemorrhages, as well as smaller cerebellar hemorrhages that result in significant brain stem compression should be evaluated. The roles of intensive medical therapy, elective late surgery and of immediate operation in improving eventual functional outcome need to be investigated further.     

Lobotomy in private practice.

In a follow-up of 43 private psychiatric patients referred for open bimedial prefrontal lobotomies between 1948 and 1970, patients were rated by personal interviews and review of medical records for symptom improvement and organic brain syndromes. Initial diagnoses were obsessive-compulsive neurotic (27), hypochondriacal neurotic (five), manic-deprresive (depressed) (one), and schizophrenic (ten). All had been severely impaired by illness intractable to extensive previous treatment. Thirty-five were found to be virtually free of symptoms that prompted operation, six had some improvement, and two were unimproved. Six had moderate to severe organic brain syndromes; three had seizure disorders necessitating treatment; and 17 incurred substantial weight gains. Best results were for hypochondriacal and obsessive-compulsive neurotic patients with phobic symptoms: poorest results were for paranoid schizophrenic subjects. This study was undertaken to provide some increment of data that could aid ongoing efforts to evaluate the consequences of this treatment.     

Empirical study on an inpatient psychogeriatric unit: diagnostic complexities

Retrospective analysis of the phenomenology and the diagnostic process of 112 consecutive psychogeriatric admissions revealed the majority (61%) were suffering from affective illness. In 53 percent, the reason for admission was depression and 8 percent were in the manic phase of a bipolar disorder. Dementia was diagnosed in 32 percent, with a third of these patients having an associated depression. The remaining 7 percent had a schizophrenic or paranoid disorder. Ninety-two patients (82%) were found to have at least one coexisting medical and/or neurological disorder(s) requiring early intervention. Associated acute organic brain syndromes were common (18%) and often difficult to diagnose. The AOBS was at times the only sign of an underlying active medical condition. The diagnosis of this condition often required serial observations for fluctuations in mental status accompanied by appropriate laboratory investigations. These findings underscore the complexity of the diagnostic process in psychogeriatric patients suffering from concomitant medical and psychiatric disorders. High index of awareness is recommended for the need to search for coexisting delirium, which may be masked at times by the major psychiatric disorder.     

Psychiatric aspects of head and neck cancer surgery

Psychiatric problems of patients with head and neck cancer include reactions to disfiguring illness and treatment; adjustment to alterations of speech, eating, and other functions, including sex; changes in body image; alcohol and tobacco addiction; pain; organic brain syndromes; and dealing with terminal illness. Although speech is often compromised, head and neck patients can communicate and psychiatric work is possible. The consultation-liaison psychiatrist can provide considerable assistance by utilizing psychodynamic, behavioral, and pharmacologic modes of treatment and by working with family members and staff.     

The psychiatrist''s role in behavioral pediatrics training programs

Behavioral pediatric fellowships are available in 15 major medical institutions in the United States. In general, these programs focus on the psychologic, social, and biologic determinants of behavior and learning disabilities in children. Child psychiatry's participation in the formulative stages of these programs is considered vital. The authors caution psychiatry to avoid concentrating its energies upon these socially and developmentally inclined behavioral pediatricians to the detriment of all pediatric house staff.     

A survey of placebo use in a general hospital

Two hundred thirty registered nurses and seventy physicians participated in a retrospective study scrutinizing placebo effects, prescribing patterns, and staff attitudes in a university-based general hospital setting. Despite copious experimental literature devoted to placebo effects over the past thirty years, the medical and surgical use of placebos seems to disregard experimental data. Although 80% of the staff had used placebos in the hospital, their knowledge of placebo effects was in many respects deficient. Within the hospital, 89% of placebo use was directed toward the amelioration of “pain”; the authors believe that emphasis should be placed on the education of staff to perceive emotional, social, and physiological concomitants of pain rather than resorting to a purely physicalistic approach. A need to acknowlege staff conflicts over the ethical use of placebos should be a significant part of this educational approach.     

Management of the borderline patient on a medical or surgical ward: the psychiatric consultant's role.

The patient with borderline personality hospitalized on a medical or surgical ward has a disorganizing effect on the house staff, who may regress in response to the patient's impulsivity, dependency, entitlement, and rage. The psychiatric consultant's role in the management of such a patient should consist of a specialized type of consultee-oriented approach in which countertransference hatred and fear, typically generated in the staff by the borderline, are drawn away from the patient and strategically metabolized within the staff-consultant relationship. The consultant should actively promote a behavioral management practicum, placed in the medical chart for reference and as a symbol of the psychiatrist's helping presence, which discusses: a) clear communication with the patient and among staff, b) understanding the patient's need for constant personnel, c) dealing with the patient's entitlement without confronting the patient's needed defenses, and d) setting firm limits on the patient's dependency, manipulativeness, rage, and self-destructive behaviors. The consultant should work to counteract feelings of helplessness in the staff, to neutralize punitive superego in the staff, and to diminish fearfulness toward the patient.     

Psychological testing and consultation-liaison psychiatry

Although the use of psychological testing in medical settings has been limited primarily to psychiatric units, it can add appreciably to teaching and diagnostic efforts on a psychiatric consultation-liaison service. A number of methodological and procedural modifications are necessary to incorporate testing into the diagnostic workup. The psychologists' efforts must be viewed as supportive, and must be geared to take into account the unique problems on medical and surgical units. Testing efforts can be most helpful in identifying: a) patients whose response set or attitude predisposes them towards exaggerating or minimizing emotional difficulties, b) individuals with conversion reactions or major psychogenic components complicating their medical disorder, and c) patients in whom an organic brain syndrome complicates medical adjustment. The MMPI and the Wechsler Adult Intelligence Scale are examples of two objective assessment instruments that can aid in dealing with an array of diagnostic problems. A series of test profiles are discussed with specific comments directed towards demonstrating the utility of psychological tests.     

Beyond "the men of steel". The origins and significance of house staff training stress

Stress is a common and significant component of house staff training. It has a dual capacity to support and hinder the trainee's education and well-being. However, there has been infrequent attention to the purpose and significance of training stress in the medical literature. The myths and traditions of medicine that foster sayings such as "in the days of the giants" or "the men of steel" do not sufficiently explain the dynamics of house staff stress. This article examines the origins, effects, and meaning of house officer stress. Stress seems to originate from as well as influence: the psychology of physicians, patient care, hospital economics, and the relationship between trainees and educators. Adaptations to stress acquired in training influence the house officer's future professional and personal well-being. Evaluation of training stress can help clarify related issues such as physician impairment and mentoring in medical education.     

Recognition of neurologic diseases in geriatric inpatients

Objectives: - To determine the prevalence of neurologic disease and the diagnostic impact of neurologic consultation on a geriatric inpatient unit. Material and methods - Consecutively admitted patients were prospectively assessed by a neurologist and by medical house staff on a geriatrics unit over a 4-month period. Neurologic diagnoses were compared. Results -Fifty-eight men, aged 76.4±8.7 years old (mean±SD), had 1.4 ± 1.1 new or revised neurologic diagnoses made by the neurologist. The prevalence of neurologic disorder was: gait or balance disorder (90%); cognitive disorders (71%); neuromuscular disorder (59%); cerebrovascular disorder (38%); and extrapyramidal disorders (22%). New diagnoses were made by the neurologist among the cognitive (40%), neuromuscular (36%) and cerebrovascular disorders (19%). Conclusions - Neurologic disease is highly prevalent in geriatric inpatients. A neurologist's assessment resulted in altered diagnoses suggesting that neurologists should play a role in geriatric assessment and in education of health professionals caring for the elderly.     

The prevalence of neuropsychiatric disorders in a nursing home population

The prevalence of neuropsychiatric disorders and other medical illnesses was investigated in 65 nursing home residents. The authors found neuropsychiatric disorders to be present in 94% of the sample. The neuropathologic causes of these syndromes were found to be more diverse than in previous studies. The most frequent causes were degenerative, vascular, and toxic. The most common psychiatric syndromes that resulted from these neuropathologic disorders were dementia syndrome (72%), organic personality syndrome (14%), and organic psychotic disorders (12%). The most common behavioral problems, agitation and aggression, most likely reflected the high prevalence of frontal lobe damage and affected 48% of the sample. Other non-neuropsychiatric medical problems were significantly less common. While only 4% of the sample had no neuropsychiatric diagnosis, 39% had no other non-neuropsychiatric diagnosis. These results suggest that the nursing home is not used as a referral source for chronic medical conditions in general but almost exclusively for the care of chronic neuropsychiatric disorders.