Teaching psychiatry to nonpsychiatrists: II. A model curriculum

It is becoming increasingly clear that psychiatric and psychosocial needs of medical patients are not being adequately met. This need has led to an increasing emphasis on the psychiatric education of nonpsychiatrists at varying levels of experience. Given the many problems involved in these educational efforts, as well as the paucity of evaluation studies and the uncertainty of results, the authors argue that the systematic application of empirically-validated educational principles may lead to greatly improved effectiveness. In the first section of a two-part series, the authors reviewed educational methodology as it relates to the development of objectives, the selection of teaching procedures, and the use of evaluation techniques. The present paper, part-two, describes in detail a “model” curriculum for primary care residents that was developed according to these principles of educational methodology.     

Change of diagnosis in schizophrenia and first-rank symptoms: An eight-year follow-up

Fifty-seven patients diagnosed as schizophrenic at the inception hospital admission, because they had Schneider's first-rank symptoms, were investigated 8 years for change of diagnosis. The average duration of their psychiatric contact after the admission was 5 years. During this period 88% still had a diagnosis of schizophrenia, but seven patients had been given other diagnoses. Change of diagnosis was significantly associated with “voices discussing” when it was the only first-rank symptom. The question of whether “voices discussing” should be included in the canon of Schneiderian first-rank symptoms is discussed.     

Student attitude changes during “Psychiatric Medicine” clerkships

Whether psychiatrists can provide effective training of medical students in the psychosocial aspects of patient care should be questioned seriously in view of numerous reports showing that psychiatric education of student physicians has often been inadequate and unpopular. Consequently, objective evidence of psychiatry's ability to enhance knowledge, and especially to change attitudes, is needed in order to substantiate its claim to a significant role in the psychosocial training of doctors. A survey of 111 medical students who completed a “Psychiatric Medicine” clerkship reveals that they developed more favorable attitudes toward psychiatry and psychiatrists, as well as toward the treatability and likability of psychiatric patients. The meaning and implications of these findings are discussed.     

Psychiatric consultation among hospitalized arthritis patients

Fifty consecutive psychiatric consultations on 48 patients over an 18-month period in an arthritis hospital are analyzed. The range of psychiatric disorders and their relationship to characteristics of the patient population, such as age, sex, and medical diagnosis, are described. Approximately 2% of patients admitted to the hospital during this period elicited psychiatric consultation. This rate is one-third of the consultation rate of an acute medical and surgical hospital serviced by the same consultants. The relative distribution of psychiatric diagnoses—depression 59%, personality disorders and drug abuse 15%, psychosis 10%, conversion reaction 10%, and “other” 6%—was similar to that encountered in an acute general hospital setting. Although depression was the most prevalent psychiatric problem, it was severe enough to elicit consultation only in 1% of the total hospitalized population; its severity did not correlate directly with the severity of rheumatoid arthritis, the most common medical diagnosis encountered. Neither a particular medical illness nor sex accounted for a disproportionate share of the psychiatric consultations.     

Depressives syndromes in a primary care setting: Evaluation,classification, and outcome

Fifteen percent of the general population may experience a major disorder of mood during their lives.¹ Their care falls to the greatest degree upon the primary physician.² A general practitioner may be chosen for the first contact by an estimated 88% of individuals fearing an experiencing psychologic disturbance.³ As many as 63% of community based mentally ill (n = 490,000) may receive their psychiatric treatment from a general practitioner.⁴ This prevalence is further enhanced by the observation that psychiatric patients represents a high medical utilization group when contrasted with nonpsychiatric controls.⁵Since the depressive syndrome is of diverse etiology, and may present under the guise of a physical complaint, a comprehensive evaluation should include a personal and family history, physical and mental status examination, and appropriate laboratory tests. While family practitioners may spend from 17% to 27% of patients care time dealing with emotionally related problems,⁶ some 60% of the American Academy of Family Physicians reported “insufficient training in medical school” to deal with their patients' emotional problems. A comprehensive data base (Table 1) was contrasted with the practices of second and third year family practice residents by a prospective study of recently diagnosed “depression” at a community primary care center.     

Behavioral precipitants of restraint in the modern milieu

Physical restraint of the psychiatric patient is a persisting reality in the acute management of uncontrolled, disruptive, or violent behavior. Depite advances in pharmacologic and milieu management, the “quiet room”, locked seclusion, or mechanical restraint often remain the last resort in control of the acutely disturbed patient. In this era of nonrestraint, little is taught or written of the practice of restraint. The literature contains few systematic studies of its persistence in modern milieu wards. The practice of restraint is viewed in resident education as an embarrassing anachronism, yet persists in some form in most clinical settings. This incongruity between teaching and practice led us to systematically survey our own use of physical restraint in an acute inpatient milieu. The diagnosis of patients restrained and the behavioral precipitants of restraint are the focus of this report.The modern therapeutic milieu stands in philosophic opposition to physical restraint by virtue of widespread acceptance of dynamic management of violent patients and confidence in the efficacy of pharmacologic treatment. The clinical belief that dynamic understanding in experienced hands can render a potential combatant “quickly cooperative”¹ is widely held. Following Connolly's famous admonition that “restraint and neglect are synonymous,”² the milieu staff shares responsibility for the patient's disruptive behavior. Violence and impulsive behavior are not so much the product of autistic process as they are defensive responses to “ambiguous, confusing, belligerent or threatening treatment.”¹ A violent outcome and resort to physical restraint implies staff failure and a punitive response to fear of the threatening patient. In his study of factors sustaining the practice of locked seclusion at the Boston Psychopathic Hospital, Greenblatt identified the “evils” of “overroutinization of use, lack of knowledge concerning the patient's feelings, poor communication about these feelings among the staff and lack of adequate motivation for serving the basic psychologic needs of the patient.”³ Attention to these dynamic considerations in a therapeutic milieu augmented by the use of potent pharmacologic agents has greatly reduced but not eliminated the use of physical restraint. The question of who is restrained on the modern milieu ward and why must be asked in this dynamic context.     

Psychiatric emergencies in travelers to Hawaii

The popularity of traveling and tourism is such that it is now commonplace for tourists to travel through several time zones and to immerse themselves for a few days in cultures very different from their own. Although the psychiatric literature contains a number of studies relevant to migrant populations, little is known about the stresses and psychiatric problems that are closely related to the travel experience itself. That emotional difficulties might be associated with travel is implied by the fact that “vacation” is worth 13 points on Holmes and Rahe's Social Readjustment Rating Scale.¹ In an exploratory study, Kimura, Mikolashek, and Kirk² stated that many newcomers to Hawaii experienced psychiatric crises resulting in their being seen in the emergency room. They hypothesized that a common dynamic among those who developed psychiatric crises was that of trying to escape problems at home but finding instead that their difficulties had come with them and were compounded by the stress of traveling and relocation. This syndrome is known locally as the “coconuts and bananas syndrome,” referring to the myth that life is so easy in Hawaii that one can simply pick food off of trees. In this paper, the psychiatric emergencies associated with travel to Hawaii are systematically evaluated and certain patterns are delineated.Hawaii is an ideal place to study the psychiatric problems associated with travel and tourism. In 1976, over 9,000 visitors entered Hawaii per day, according to data from the Hawaii Visitors Bureau. The daily census of tourists on the island of Oahu alone was about 77,000. The great majority of newcomers to Hawaii are, of course, tourists, but some come for other reasons including relocation. This group accounted for roughly 2,500 persons per month. The present study was untertaken to discover more fully the psychiatric problems of newcomers to Hawaii.     

Medical and surgical consultations to a general hospital psychiatric unit

This study reviews 563 medical and surgical consultations to a general hospital psychiatric unit over three years. In addition to an analysis of the consultations by service and month, consulted patients are compared with nonconsulted patients by age, sex, and diagnosis. Parallels are drawn to psychiatric consultations as reported in the consultation-liaison literature to medical and surgical patients. Two important findings from the present study are that depressed patients received significantly (P < 0.01) fewer consultations than expected, and that 49% of one year's consultations were for active medical problems not related to the reason for psychiatric admission.     

Teaching psychiatry to non-psychiatrists: I. The application of educational methodology

It is becoming increasingly clear that psychiatric and psychosocial needs of medical patients are not being adequately met. This need has led to an increasing emphasis on the psychiatric education of nonpsychiatrists, at varying levels of experience. Given the many problems involved in these educational efforts as well as the paucity of evaluation studies and the uncertainty of results, the authors argue that the systematic application of empiricall validated educational principles may lead to greatly improved effectiveness. In this first section of a two-part series, the authors review educational methodology as it relates to the development of training objectives, the selection of teaching procedures, and the use of evaluation techniques. Part two presents a detailed “model” curriculum for primary care residents, developed according to the principles of educational methodology.     

A legal-questionnaire study of psychiatric inpatients and medical surgical outpatients

Prior to the Vietnam era a high percentage of patients hospitalized in Veterans Administration Hospitals for psychiatric illness could be described as marginal men.¹ These patients are characterized by poor occupational history, poor marital adjustment, a nomadic existence, dependency on an institutional way of life, and alcoholism. Both authors have noted that this type of patient seems to have more than his share of legal problems. Oftentimes the legal problems seem to be of top priority to the patient, i.e., unless they are solved, the patient cannot expect to make an adjustment within the community. A literature review revealed no information on the extent of this problem. The social psychiatric kinds of intervention employed in the treatment of these patients requires that all social factors be considered simultaneously with psychodynamic and biological factors in the patient's course. As part of an attempt to develop more meaningful interventions with this patient population,² we designed a survey to determine the extent of legal problems. It attempts to answer the following questions: Are psychiatric patients more prone to have legal problems than a medical surgical outpatients population? Are there any particular kinds of legal problems which differentiate the psychiatric population from the medical surgical out-patient population?     

Psychiatric service planning: beds in perspective.

The origins and validity of the British national planning “norm” for psychiatric beds are discussed. Evidence of present and future use of psychiatric beds is drawn from a number of studies relating to the remnant of earlier long-stay cohorts, the current accumulation of new long-stay patients, and the present use of beds for short and medium stays.The use of “beds” in the context of a comprehensive psychiatric service and the dangers of planning beds in isolation are discussed. Suggestions are made for an alternative approach to “norms” and psychiatric service planning.     

Psychiatry's identity crisis: a critical rational remedy.

Psychiatry has several partial identities reflecting its biologic, psychoanalytic, and social subspecialities. It has, however, no encompassing professional identity. This identity requires three features: (a) a common language and procedure for assessing psychopathology, (b) a common method for evaluation and use of knowledge from outside psychiatry, and (c) a common set of values regarding clinical and research activities. The authors discuss the clinical, biologic, and sociocultural psychiatric traditions to identify the roots and consequences of psychiatry's fragmented state. Psychiatry's identity problems cannot be solved by ignoring them or simply becoming more "medical." Rather, the authors propose a remedy--critical rationality--to help resolve the crisis. Critical rationality requires a discimplined approach to psychiatric knowledge that underscores the necessity of methodologic rigor, practicality, and mid-range theorizing (rationality); and the equal necessity for systematic self-criticism, reform, self-awareness, and attention to the ethical dimensions in teaching, practice, and research (critical).     

The relevance of a staff-oriented approach in consultation psychiatry: A preliminary study

According to the literature, a patient-staff conflict or intra-staff conflict is often the hidden reason for requesting a psychiatric consultation. This study is specifically directed at determining the percentage of consultations in which such “staff problems” play a clinically relevant role. Indications of staff problems were found in one-third of 313 consultations investigated. These problems occurred significantly more frequently in patients admitted to surgical wards and in patients referred because of psychological disturbances related to their physical disorder, with a diagnosis of “transient situational disturbance” or “no psychiatric disorder”. Consultants with relatively less experience diagnosed significantly more staff problems. In about half of the consultations with staff problems, a staff-oriented approach was applied. Lack of communication with the ward staff in question was the most frequent obstacle to applying such an approach.     

Defining psychiatry in primary care: Origins,opportunities, and obstacles

Society's demand for more comprehensive health services, and psychiatry's pursuit of a more medical orientation, have together fueled interest in the psychiatric aspects of primary care medicine. We have begun to define the content of the field by transplanting selected aspects of existing clinical psychiatry into this new setting. Yet general medical patients present new types of psychiatric, interpersonal, and behavioral problems, and the psychosocial aspects of the medical care process are important in primary care. We need to acknowledge these characteristics in establishing a body of knowledge and clinical investigation that comprise the psychiatric aspects of primary care. Doing so will make our teaching and clinical care in primary care settings more valuable, will establish a solid academic foundation for the field, and will help to subject the “art” of medicine to more rigorous study.     

The significance of biological factors in the diagnosis of depressions: II hormonal variables

The reasons behind the recent upswing in psychoendocrinology are discussed, with reference also to the relation between MA research and hormone studies. The question is raised whether hormonal research has yielded data of diagnostic value. Data that warrant predictions about the choice of antidepressant and the prognosis of the depression considered.Three function tests are discussed in this context: the DST, the TRH/TSH test, and growth hormone responses to various stimuli. These three “tests” can all be disturbed in depressions, but probably in particular in some of the endogenous (vital) depressions. These findings, like the biochemical data, support the concept of the pathogenetic heterogeneity of the vital depressions. We do not know whether the disturbances described are all observed in the same patients or are characteristic for various subgroups. DST disturbances were found to be highly specific: characteristic for the subgroup of endogenous depressions. The specificity of the other “tests” had not yet been adequately studied. Data on their therapeutic and prognostic significance, although promising as such, are still scantly. Any conclusion concerning their value in psychiatric practice would therefore be premature.     

Medical clinic referrals to psychiatric social work: review of 100 cases

This study examines 100 consecutive patient referrals from a general medical clinic to psychiatric social work. While much has been written from a theoretical or anecdotal perspective on the contribution of social work to medical care, there have been relatively few attempts to look in detail at actual practices. Of the 100 patients, 52 were referred for "concrete services," 30 for evaluation of a psychiatric disorder (such as depression or somatoform disorder), 20 for counseling, and 11 for assistance for a drug or alcohol problem. Although the most frequent referral to psychiatric social work by the medical clinic staff was for concrete services, half of these cases actually involved overlooked psychiatric problems, and no concrete service of any sort was perceived as necessary by the psychiatric social worker in 30% of these cases. Referring medical staff tended to view patient distress in terms of concrete needs and chose to refer to social work even when significant psychiatric diagnostic problems were identified. Analysis of the differences in reasons for referral versus actual clinical problems has implications not only for the training needs of social work in this setting, but also for the relationship between social work and psychiatry, and for the organizational and educational needs of ambulatory medical services.     

Inadequate Effort on Neuropsychological Evaluation is Associated With Increased Healthcare Utilization

Patients who exert inadequate effort on neuropsychological examination might not receive accurate diagnoses and recommendations, and might not cooperate fully with other aspects of healthcare. This study examined whether inadequate effort is associated with increased healthcare utilization. Of 355 patients seen for routine, clinical neuropsychological examination at a VA Medical Center, 283 (79.7%) showed adequate effort and 72 (20.3%) showed inadequate effort, as determined at time of evaluation using the Word Memory Test and/or Test of Memory Malingering. Utilization data included number of Emergency Department (ED) visits and inpatient hospitalizations in the year following evaluation. Patients who had shown inadequate effort on examination had more Emergency Department visits, more inpatient hospitalizations, and more days of inpatient hospitalization in the year after evaluation, compared to patients who had exerted adequate effort. This finding was not attributable to group differences in age or medical/psychiatric comorbidities. Thus, patients who exerted inadequate effort showed greater healthcare utilization in the year following evaluation. Such patients might use more resources since diagnostic evaluations are inconclusive. Inadequate effort on examination might also serve as a “marker” for more general failure to cooperate fully in one’s healthcare, possibly resulting in greater utilization.     

“Selected truth”

Professional staff in the National Health Service tend to assume without question that the patients they meet are genuine, honest, and well-intentioned in the problems that they present. The same applies to the parents and relatives of patients, and to professional associates. The large majority are, so that any rare exceptions appear almost incredible. In this respect interviews with doctors and other health workers differ from those with lawyers and the police where the veracity and goodwill of the client is not automatically taken for granted. Downright deliberate dishonesty or premeditated manipulation of truth on the part of patients, their relatives, and people caring for them may be construed as reflecting some personality or psychiatric disorder. Milder forms and shades of “near truth”, “selected truth”, “graduated truth”, “white lies”, “exaggerated facts”, and data chosen for maximum impact, are more frequent and are probably not always suspected or detected. In all communications between people, degrees of licence and flexibility are found, and are institutionalised in different societies and cultures. For example, it has been good manners in Britain not to be too outspoken or blunt, and to use understatement. This is reminiscent of Voltaire's “Speech was given to man to conceal his thoughts.” The term “graduated truth” is used in medical work when it is thought to be in the interests of the patient to deliberately and knowingly conceal or modify the truth. This paper considers some facets of services for mentally handicapped people where “graduated truth” is used in practice. These are: selectivity of data; differential behaviour; fabrication, fantasy and make-believe; and patient management.     

The “least restrictive environment”: From Rhetoric to Practice

During the past 10 years, more and more general hospitals have opened psychiatric units, many of which represent the best of modern hospital psychiatry. Therapeutic success on these units is based on control of admissions as well as on clinical programs. Pressure from the State to admit involuntary patients, recently justified by the doctrine of the “least restrictive environment”, threatens to erode the quality of treatment now being provided. The concept of “least restrictive environment” is ambiguous and sometimes misleading. The treatment of involuntary psychiatric patients in general hospitals, in order to be safe and effective, requires the resolution of legal, clinical, financial, and architectural issues, as well as problems in the relationship between psychiatric units and other areas of the general hospital.