Consultation Psychiatry in a Japanese General Hospital: Patients Referred to Psychiatric Consultation*

Abstract: A total of 164 (47%) out of 350 new psychiatric patients in a general hospital in Japan were those referred to psychiatric consultation. In 47% of the cases, concurrent physical and psychiatric disorders were reported. In the referred patients, neurosis (38%) was the most common psychiatric disorder, followed by other nonorganic psychoses (9%), schizophrenic psychoses (8%), alcoholic psychoses (8%), transient organic psychotic conditions (7%), affective psychoses (6%) and others. The high frequency of psychiatric emergency cases (23%) including cases with suicide attempts (12%) indicated that psychiatrists play an important role in psychiatric emergency crisis intervention in the general hospital emergency service. In suicide attempts, depression was most prominent, but schizophrenic psychoses were also involved in a third of the cases.     

Consultation psychiatry in a Japanese general hospital: patients referred to psychiatric consultation

A total of 164 (47%) out of 350 new psychiatric patients in a general hospital in Japan were those referred to psychiatric consultation. In 47% of the cases, concurrent physical and psychiatric disorders were reported. In the referred patients, neurosis (38%) was the most common psychiatric disorder, followed by other nonorganic psychoses (9%), schizophrenic psychoses (8%), alcoholic psychoses (8%), transient organic psychotic conditions (7%), affective psychoses (6%) and others. The high frequency of psychiatric emergency cases (23%) including cases with suicide attempts (12%) indicated that psychiatrists play an important role in psychiatric emergency crisis intervention in the general hospital emergency service. In suicide attempts, depression was most prominent, but schizophrenic psychoses were also involved in a third of the cases.     

Axis I and Axis II diagnoses in patients with chronic idiopathic urticaria

OBJECTIVE: This study presents the current prevalence of Axis I and Axis II psychiatric diagnoses and factors associated with the existence of Axis I psychiatric disorders in patients with chronic idiopathic urticaria (CIU). METHOD: The study sample was composed of 89 patients with CIU and 64 control subjects. Axis I and Axis II psychiatric disorders were ascertained by means of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition and the Structured Clinical Interview for DSM, Revised Third Edition Personality Disorders, respectively. RESULTS: Of patients with CIU, 44 (49.4%) had at least one Axis I diagnosis, and 40 (44.9%) had at least one personality disorder. The most common Axis I disorder was obsessive-compulsive disorder (25.8%), and the most common Axis II disorder was obsessive-compulsive (30.3%) personality disorder in patients with CIU. Obsessive-compulsive disorder, major depression, obsessive-compulsive and avoidant personality disorders were more prevalent in patient group compared to control group. Obsessive-compulsive and avoidant personality disorders were related to the existence of Axis I disorders in patients with CIU. CONCLUSION: Psychiatric morbidity seems to be a frequent healthy problem in patients with CIU.     

High rates of psychiatric co-morbidity in individuals with Asperger's disorder

The present study aimed to provide clinical data regarding co-morbidity of psychiatric disorders in individuals diagnosed with Asperger's disorder (AD). This study included 37 individuals (32 male, five female, mean age: 10.9±4.5 years) diagnosed with AD. Psychiatric comorbidity was assessed using the Schedule for Affective Disorders and Schizophrenia for School Age Children – Present and Lifetime Version (K-SADS – PL). Ninety-four percent of participants had at least one additional psychiatric disorder. The most common were anxiety disorders (54%), disruptive behavioural disorders (48%), and mood disorders (37%). The results of this study highlight the need for detailed assessment of additional psychiatric disorders in this population.     

Psychogenic movement disorders

All varieties of movement disorders may be mimicked by a psychogenic disorder, most commonly tremor, dystonia, and myoclonus. Approximately 3% of patients seen in specialty clinics have a psychogenic movement disorder (PMD). The diagnosis of a PMD depends on not just ruling out an organic movement disorder, but moreover, recognizing features from the history and examination that are inconsistent or incongruous with an organic movement disorder. Most PMDs represent a conversion disorder, sometimes as part of a somatoform disorder; less common diagnoses include a factitious disorder or malingering. Co-morbid psychiatric illness is prevalent in patients with PMD including depression, anxiety, and personality disorders. Many PMDs remain chronic, but a multidisciplinary approach centering on psychiatric intervention can be successful. A shorter duration of symptoms and a co-existent treatable psychiatric disorder portend a better prognosis, whereas compensation and pending litigation are associated with a poorer prognosis.     

Psychiatric co-morbidity in 75 patients undergoing epilepsy surgery: lack of correlation with pathological findings

BACKGROUND: Psychiatric disorders may occur in patients with intractable partial epilepsy after surgical treatment. Previous reports attributed the presence of psychological adverse events to specific pathological entities such as dysembryoplastic neuroepithelial tumors (DNETs) and gangliogliomas. The rationale for the present study is to evaluate the importance of the surgical pathology in individuals undergoing epilepsy surgery. METHODS: The patients were separated into three groups based on the surgical pathology: group I ganglioglioma (N=25), group II DNETs (N=25), and group III mesial temporal sclerosis (N=25). Thirteen of the 75 patients (17.3%) had a preexisting psychiatric disorder. The most common preoperative psychiatric diagnosis was depression (N=4). Sixty-three of the lesions (84%) were restricted to the temporal lobe. The operative strategy included resection of the lesion and epileptogenic cortex. Sixty-two of the 75 patients (83%) were rendered seizure-free. RESULTS: Eight of the 75 patients (10.7%) had an acquired psychiatric illness following surgical treatment. A mood disorder developed in three patients after surgery. No statistical difference emerged in preoperative psychiatric co-morbidity (no group difference; p=1.0) or in newly diagnosed postoperative psychiatric disease (group I vs. II, p=0.67; group I vs. III, p=1.0; and group II vs. III, p=0.67) within the three surgical pathology groups. CONCLUSION: This study indicates that the presence of psychiatric disease before and after surgery for intractable partial epilepsy, predominantly of temporal lobe origin, was independent of the pathological findings.     

Consultation psychiatry in an Italian general hospital: A report on 500 referrals

Five-hundred consecutive referrals to the psychiatric consultation service at the University of Padua School of Medicine have been reviewed. In 69% of cases concurrent physical and psychiatric disorders were reported. There was a prevalence of females, working class patients, and individuals with limited schooling. Depression was the most common psychiatric disorder in all classes of organic disease and accounted for 37% of all psychiatric diagnoses, followed by anxiety neurosis (18.6%) and drug dependence (13.8%). In 10.8% of cases no psychiatric diagnosis was made.     

Psychiatric morbidity and HIV in female drug dependants in Malaysia

Female drug dependants (n = 171) and controls (n = 1137) were studied to search for psychiatric morbidity in them. The psychiatric morbidity was found to be 36.3% and 6.9%, respectively. The most common psychiatric disorder found was dysthymic disorder followed by adjustment disorder, anxiety disorder and borderline personality disorder. The diagnosis was significantly dependent on the type of drug used (P < 0.001) and HIV seropositivtty status of the patients (P = 0.04). The findings highlight the relationship of the psychiatric morbidity to the HIV status and female drug users.     

Geropsychiatric consultation in a general hospital in Taiwan

The aim of this study was to characterize clinically significant issues in a psychiatric consultation service for geriatric inpatients in a general hospital in Taiwan. This was a case-control study. During a 5-month period, 100 geriatric (age > or =65 years) inpatients consecutively referred for consultation-liaison psychiatric service from non-psychiatric departments formed the study group. Another 100 medical inpatients, also referred for consultation-liaison to the psychiatric service, but aged 17-50, formed the control (non-geriatric) group. The diagnosis, demography, reason for referral, symptomatology, and other clinical characteristics were determined by consensus between two psychiatrists. Psychiatric diagnosis was made according to criteria in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders. The geropsychiatric consultation rate was 0.9%. Geriatric patients constituted 20.1% of all psychiatric referrals. Common reasons for referral of geriatric inpatients were confusion (32%), depression (17%), disturbing behaviors (14%), and psychosis (14%). The most common psychiatric disorder among geriatric patients was an organic mental disorder (79%), followed by a depressive disorder (13%). More geriatric patients suffered from cancers and cerebrovascular diseases than non-geriatric patients. The geriatric group was more likely to have multiple physical illnesses. Organic mental disorder and depressive disorders are the most common psychiatric diagnoses in the geropsychiatric consultation service of the authors. In the authors' experience, both psychotropic medication treatment and psychosocial intervention are important in geropsychiatric consultation.     

Mental disorders in general hospital patients

Two major epidemiological studies using standardized instruments for diagnosis have revealed that the prevalence of mental disorders in general hospital inpatients range from 41.3% to 46.5%. The most prevalent groups of psychiatric disorders among general hospital inpatients are organic mental illness, depressive disorders, and alcohol dependence or abuse. The prevalence rates of organic brain syndromes, adjustment disorders with depressed mood, and alcohol dependence in general hospital inpatients are above those of the general population. In nearly half of the studied general hospital inpatients receiving a psychiatric diagnosis Consultation-Liaison (C-L) psychiatry interventions were found to be necessary. However, psychiatric consultation rates found in most recently presented studies in Germany and Austria range from 2.66% to 3.30%, and remain low when compared to the reported prevalence figures of psychiatric disorders and the demonstrated necessity for specific therapeutic interventions among general hospital inpatients. There is also evidence stemming from newly presented C-L follow-up studies that the remarkable advances in intensive care treatment, organ transplantation medicine and cardiac surgery with cardiopulmonary bypass within the past decade have an important impact on the general hospital inpatients; psychosocial outcome. One follow-up study of long-term acute respiratory distress syndrome (ARDS) survivors using the Structural Clinical Interview for the DSM-IV (SCID) has shown that 43.5% of these patients met the criteria for a full posttraumatic stress disorder (PTSD), 8.9% of these patients for a subthreshold or partial PTSD (sub-PTSD) at hospital discharge, and 23.9% of them still suffered from full PTSD, 17.8% of them from sub-PTSD. ARDS-Patients with PTSD symptomatology exhibited major impairments in a variety of dimensions of health-related quality of life. Another outcome study examining concurrently psychiatric morbidity and quality of life in intermediate-term survivors of orthotopic liver transplantation (OLT) survivors has documented that 5.4% of these patients had a full PTSD, and 17.3% of them a sub-PTSD at 4 year-follow-up. OLT- related PTSD symptomatology was associated with maximal decrements in health-related quality of life. The duration of intensive care treatment, the number of medical complications, and the occurrence of acute rejection were positively correlated with the risk of PTSD symptoms subsequent to OLT. Finally, one prospective 1-year outcome study has focused on psychiatric morbidity including postoperative delirium in patients who had undergone cardiac surgery employing cardiopulmonary bypass. Postoperative delirium developed in 32.4% of these patients, however, only in 5.9% of them severe delirium was noted. Short-term consequences of cardiac surgery included adjustment disorders with depressed features (32.4%), acute full in-hospital PTSD (17.6%), and in-hospital major depression (17.6%). The diagnostic status of in-hospital PTSD was linked to postoperative delirium. At 12 months, the severity of depression and anxiety disorders including PTSD improved and returned to the preoperative level. However, patients who were found to have major depression or PTSD before discharge, C-L psychiatric consultations were conducted. In conclusion, PTSD symptoms following medical illness and treatment are not rare. If they are untreated, PTSD symptoms such as intrusive recollections, avoidance and hyper-arousal may impair the patients; quality of life more than the primary disease. This seems to be also true for a subthreshold PTSD. To adequately diagnose and treat patients at risk of developing PTSD, close collaboration between physicians of all subspecialties and C-L psychiatrists will be necessary.     

Psychiatric and personality disorders in deliberate self-harm patients

BACKGROUND: Previous UK studies have reported much lower rates of psychiatric and personality disorder in those who attempt suicide than in those who die by suicide. AIMS: To determine the nature and prevalence of psychiatric and personality disorders in deliberate self-harm (DSH) patients. METHOD: A representative sample of 150 DSH patients who presented to a general hospital were assessed using a structured clinical interview and a standardised instrument. Follow-up interviews were completed for 118 patients approximately 12-16 months later. RESULTS: ICD-10 psychiatric disorders were diagnosed in 138 patients (92.0%), with comorbidity of psychiatric disorders in 46.7%. The most common diagnosis was affective disorder (72.0%). Personality disorder was identified in 45.9% of patients interviewed at follow-up. Comorbidity of psychiatric and personality disorder was present in 44.1%. CONCLUSIONS: Psychiatric and personality disorders, and their comorbidity, are common in DSH patients. This has important implications for assessment and management.     

Mortality among patients in psychiatric hospitals in Germany

Data from 7 psychiatric hospitals with defined catchment areas were analyzed; 14,195 episodes of treatment in acute psychiatry wards were recorded within 30 months. During their stay in hospital 196 patients died, 174 from natural causes and 22 by suicide, compared to the expected 32 deaths. Standardized mortality ratios (SMRs) were calculated for the different diagnostic and age groups, mortality risk being highest in organic mental disorder (SMR 7.59, followed by functional psychoses (SMR 4.55) and the “other disorders” (alcoholism, neurotic and related disorders, SMR 3.25). Roughly one half of the 196 deaths were due to cardiovascular disorders and pneumonia. In patients with nonorganic psychiatric syndromes, suicide was the most frequent cause of death (21 of 58 fatalities). With regard to the elevated mortality risk of patients with acute mental illness, a reduction of fatality rates from natural and unnatural causes should remain a major objective of hospital care in psychiatry.     

Adolescent adjustment disorder: Precipitant stressors and distress symptoms of 89 outpatients

ObjectiveResearch on adolescent adjustment disorder (AD) is scarce. We characterized adolescent outpatients with AD in psychosocial background and treatment received compared with patients with other non-psychotic disorders (OND). Furthermore, we explored precipitant stressors, distress symptoms and behavioral problems among males and females with AD.MethodData were collected prospectively on 290 consecutive psychiatric outpatients, aged 12–22 yrs, at a secondary care clinic in Finland. DSM-III-R diagnoses were assigned, based on all available information, at the end of treatment.ResultsAD was the second most common diagnosis among non-psychotic patients (31% of 290). Compared to OND-patients, those with AD were predominantly female and had less severe psychosocial impairment. In multivariate comparisons school-related stressors, problems with law and restlessness characterized males, and parental illness and internalizing symptoms females with AD. Intensity and duration of treatment of AD-patients varied widely.ConclusionsAdjustment disorder comprised a common clinical entity among adolescent outpatients. Psychiatric assessment and treatment should be individually targeted by taking into account gender-specific stressors and distress symptoms among young people with AD.     

Depression and its relation to lesion location after stroke

The study of discrete organic cerebral lesions resulting inclearly definable psychiatric disorders may provide an understanding ofthe underlying patho-physiological basis of these disorders. However,the relation between lesion location and psychiatric illness afterstroke remains unclear. Fifty five patients referred to hospital wereidentified who had a single lesion on CT which was consistent withtheir neurological presentation and who did not have evidence of apersistent affective disorder at the time of the stroke. Six monthsafter stroke standardised psychiatric assessment disclosed that 26% ofthe patients met DSM-IV criteria for an anxiety or depressive disorder,with depression the most common diagnosis (20%). Pathologicalemotionalism was diagnosed in 18% of patients, particularly those whowere depressed (p<0.0001). Depression was significantly associatedwith larger lesions involving the right cerebral hemisphere (p=0.01).The importance of depression as a consequence of stroke has beenclarified by the studies in this area. However, wide confidenceintervals support the possibility that significant results may be dueto chance. A systematic review of these studies is now needed if aconsensus is to be reached.

     

The art of prescribing pharmacological management of adult ADHD: implications for psychiatric care.

QUESTION: For several years I have seen more adults presenting with attention-deficit/ hyperactivity disorder (ADHD). I realize that historically ADHD has been considered a childhood disorder, but I would like to know more about diagnosing and treating adult ADHD. ANSWER: Your observations about the prevalence and challenges that confront psychiatric nurses concerning the diagnosis and treatment of adult ADHD are correct. ADHD is a relatively common psychiatric disorder with a high occurrence of 2-6% in adults (Kessler et al., 2006). Though generally regarded as a childhood diagnosis, emerging evidence indicates that symptoms of ADHD remain into adulthood, affecting 4.4% of the adult population (Biederman, Monuteaux, et al., 2006). ADHD in adults frequently goes undiagnosed and untreated. This is largely associated with adults minimizing the severity of symptoms and being unaware that they actually have ADHD. Predictably, adult ADHD is associated with increased morbidity. Higher divorce rates, traffic violations, and negative occupational, economic, and psychosocial functions and concomitant psychiatric disorders are common findings in adults with ADHD (Kessler, Adler, Ames, Barkley, et al., 2005). Approximately 70-75% of adults presenting for treatment of ADHD have at least one co-existing psychiatric diagnosis (Kessler et al., 2006; Wilens, Biederman, & Spencer, 2002). Social phobia, bipolar disorder, major depression, and alcohol dependence are the most common co-existing psychiatric disorders in adults with ADHD (Kessler et al., 2006).     

The Art of PrescribingPharmacological Management of Adult ADHD: Implications for Psychiatric Care

QUESTION.  For several years I have seen more adults presenting with attention-deficit/ hyperactivity disorder (ADHD). I realize that historically ADHD has been considered a childhood disorder, but I would like to know more about diagnosing and treating adult ADHD.
ANSWER.  Your observations about the prevalence and challenges that confront psychiatric nurses concerning the diagnosis and treatment of adult ADHD are correct. ADHD is a relatively common psychiatric disorder with a high occurrence of 2–6% in adults ( Kessler et al., 2006 ). Though generally regarded as a childhood diagnosis, emerging evidence indicates that symptoms of ADHD remain into adulthood, affecting 4.4% of the adult population ( Biederman, Monuteaux, et al., 2006 ).
ADHD in adults frequently goes undiagnosed and untreated. This is largely associated with adults minimizing the severity of symptoms and being unaware that they actually have ADHD. Predictably, adult ADHD is associated with increased morbidity. Higher divorce rates, traffic violations, and negative occupational, economic, and psychosocial functions and concomitant psychiatric disorders are common findings in adults with ADHD ( Kessler, Adler, Ames, Barkley, et al., 2005 ).
Approximately 70–75% of adults presenting for treatment of ADHD have at least one co-existing psychiatric diagnosis ( Kessler et al., 2006 ; Wilens, Biederman, & Spencer, 2002 ). Social phobia, bipolar disorder, major depression, and alcohol dependence are the most common co-existing psychiatric disorders in adults with ADHD ( Kessler et al., 2006 ).     

Child psychiatric disorders in a primary care Arab population

OBJECTIVES: Physical and psychiatric comorbidity is relatively common in general practice but there have been few systematic studies using clinical interviews of children attending the primary care services in the Arab population, and none from the Gulf countries. This study was undertaken to determine the prevalence and nature of child psychiatric morbidity in primary care in the United Arab Emirates (UAE). METHOD: Systematic psychiatric evaluations were carried out on consecutive children aged 6 to 18 years visiting their primary care doctors in Al Ain. The sample consisted of 141 (50.7%) boys and 137 (49.3%) girls. RESULTS: Forty-three percent of the 278 children received a DSM-IV diagnosis. Of these, 46 (38%) were males and 74 (62%) were females. However, only 1.1% (3/120) of the patients consulted general practitioners for a primary psychiatric symptom. The most common diagnosis was anxiety disorder followed by depression. Obsessive compulsive disorder was present in 11%, conduct disorder in 7%, and attention deficit hyperactivity disorder in 3% of those with a diagnosis. A statistically significant association was found between DSM-IV caseness and female gender, higher number of children in the household, relationship problems in the family, physical illness and family history of psychiatric disorder. Other factors that did not show any significant association were age, nationality, socioeconomic status, parental education or occupation, scholastic performance or developmental delay in the child, or parental consanguinity. CONCLUSION: Our findings suggest that psychiatric disorders are common among young people of Arab origin attending primary care facilities, and that doctors need to be vigilant about this possibility.     

A study of crying in medically and surgically hospitalized patients

In a prospective study of hospitalized patients referred to a psychiatry consultation service, 46 patients were referred for a presumed diagnosis of depression because crying was a prominent symptom. Psychiatric consultation determined that 20% had a psychiatric disorder only, 33% had a neurological disorder only, 43% had both psychiatric and neurological disorders, and 4% had a previously undescribed entity, "essential" crying. The most common neurological disorder in these crying patients was bilateral hemispheric dysfunction associated with dementia or delirium; the most common psychiatric disorder was major depression. Effective therapy for patients who cry depends on proper identification of the cause of crying.