The gap between psychiatric practice and the medical model

The authors have attempted to pinpoint causes for the disparity between the information psychiatrists say they give to referring physicians and patients and the information the referring physicians and patients say they receive. Using questionnaires and open-ended interviews, this study has shown there was a highly significant discrepancy between the information patients said they received and what psychiatrists said they gave with respect to the rationale of treatment prognoses with or without treatment.This gap could be attributed to various factors, among them the unavailability of psychiatrists or lack of outcome studies. Moreover, this study tends to point out the sequential difference in the treatment of psychiatric outpatients, e.g. the patient is helped by his doctor through treatment to diagnose himself and that adherence to this psychiatric style of interviewing could be utilized by the primary physician to improve his rapport with patients and, perhaps, increase their knowledge and understanding of their own disease.As previously reported, residents in child psychiatry, working under the supervision of the senior author, were reluctant to commit themselves to a diagnostic framework and completely avoided formulating prognoses, even though they were accomplished in understanding and conveying clinical data. The primary aim of our work was to attempt to link our trainees psychiatric and medical identities, which appeared to be totally divergent. In all of the cases covered by our study the trainees failed to provide diagnoses to referring physicians 48% of the time and to patients 45% of the time.¹ Prognoses were never offered. We have attempted to elicit reasons for this divergence from standard medical practice.     

An epidemiologic study of deaths of psychiatric inpatients.

There have previously been several studies of deaths of psychiatric inpatients, mainly in northern European countries and the U.S.^1–10 Alström,⁶ Odegard,⁷ and Malzberg⁸ reported that the patients admitted for the first time to mental hospitals have a relative risk of death four to ten times higher than that of the general population and concluded that this was attributable to conditions specifically associated with the hospital facilities and with the hospitalized patient group.The physical conditions of mental hospitals have undergone major changes over time and so have the psychologic and social characteristics of hospitalized patient groups. As a result, factors associated with patients' deaths have also been subject to changes with this passage of time. From the epidemiologic point of view, studies of psychiatric patients who have died in mental hospitals may therefore raise interesting questions.Using two sources of information, i.e., death certificates and mental hospital discharge records, the author has investigated all psychiatric patients who have died in the mental hospitals of Kanagawa Prefecture for 3 years. These deaths have then been related to total deaths in the general population of the Prefecture in the same period.     

Psychiatric symptoms in white and black inpatients. II: Follow-up study

This study is a follow-up of 109 initially undiagnosed psychiatric inpatients; 37 patients were black and 72 patients were white and the mean follow-up period was 39 months. The rate of follow-up was 95% of the designed group for the study. This study confirmed the finding of a previous chart review study that black patients have a significantly higher rate of delusions and hallucinations and this difference cannot be accounted for by a difference in diagnosis. The diagnoses in both studies were established by using a structured interview from which symptoms were extracted to meet rigorous criteria for psychiatric diagnoses. These findings of the follow-up study in addition to those of the chart review study further support the suggestion that the difference in symptomatology is characteristic more of the group rather than the psychiatric disorder.The concordance between the established diagnoses at the time of the follow-up as compared to the diagnoses of the chart review is high in the two groups. However, when an attempt was made to arrive at a diagnosis by a non-systematic clinical impression there was a significantly higher rate of error for black patients as compared to white patients. This finding suggests that a structured interview is of particular importance as a diagnostic tool for black patients.     

Psychiatric symptoms in white and black inpatients. I: Record study

The frequency of symptoms of 256 patients who were discharged from an inpatient service as undiagnosed were compared by race, sex, and age. The symptoms that were significantly more frequent in the black patients were dull affect, delusions of grandeur, delusions of body change (females only), delusions of passivity, fighting, auditory and visual hallucinations, concrete proverb interpretation (males only), psychomotor retardation (females only), decreased need for sleep (males only), increased speech (males only), and vague history (males only). Other variables more frequent in the black patients were age of first psychiatric and first Renard admissions less than 30, and treatment with major tranquilizers during first hospitalization. The only symptom recorded more frequently in the white patients was depressed affect.Sixty-eight percent of the patients met the rigorous criteria for a diagnosis and no significant difference in frequency of diagnosis (includes patients who remained undiagnosed) was found between white and black patients.Greater association was found between symptoms and diagnosis in the white population than in the black population.Because the differences in symptoms between black and white patients could not be explained by a difference in frequency of psychiatric disorders, because selection factors prompting hospitalization and quality of symptoms were not different for the groups, and because the association of symptoms with specific psychiatric diagnoses was greater in the white population than in the black, further support for the possibility that psychiatric symptoms are associated with a certain group of patients is required.     

The effect of psychiatric hospitalization in crisis.

Heber butts,² a Navy psychiatrist, reported in 1912, that “there is being established at the Naval Hospital, Washington, D.C., a psychopathic ward for the observation and treatment of certain insane officers and enlisted men of the Navy and Marine Corps. This ward, I am certain, will prove an excellent adjunct to the service in adding to the efficiency of its Medical Corps. Cases of slight or temporary mental disorder can easily be cared for in this ward until they get well; they will be at all times under the immediate control of officers of the service, and they will escape the stigma of having been an inmate of an insane asylum. In this way, the best interests of the mentally sick officers and men will be subserved. It is my opinion that a small percentage can, after their recovery, properly be restored to duty, but the great majority will, I think, be found unfit for further continuance in the service.”Thus, the incorporation of a psychiatric ward with a general hospital to provide short-term treatment and expeditious disposition consistent with the mental status of the patient has been practiced for over 60 years by the Navy Medical Department.Several researchers have indicated that acute psychiatric intervention^5–8 and brief hospitalization^4,9 are applicable as a therapeutic procedure for treating patients, but the long-term effectiveness of brief psychiatric hospitalization has not been reported. Recent research has shown that Navy psychiatrists recommended 32% of the sailors be returned to duty following their hospitalization.³ In that report, the mean length of time hospitalized was 60 days.This is a report of patients admitted to the Psychiatric Service at the Navy Regional Medical Center, San Diego, Calif., who were hospitalized 48 hr or less. These patients have been followed up to measure the effect of that brief psychiatric hospitalization on subsequent job performance. The report will deal in depth with the short-term admissions and comparisons will be made with patients who were hospitalized for a period exceeding 48 hr in order to determine with which patients short-term treatment may be effectively used. A comparative evaluation of long-term versus short-term treatment is not intended.     

A brave new world revisited: alphas, betas, and treatment outcome

This article reviews the clinical research studies that form the basis for the joint hypothesis that certain therapists (A's) obtain better results in schizophrenia while others (B's) do better with neurosis. A number of methodological problems are discussed, with particular reference to the A-B scales themselves, methods of analysis and validation, and other factors that need to be taken into consideration in the interpretation of results. It is concluded that the hypothesis has not been sustained by subsequent work. Possible explanations for the original findings include methodological artifact, therapist and patient sample differences in sex and socioeconomic class, and the effect of the expectations of the therapists' supervisors.     

A study of psychiatric syndromes manifested at an international airport.

It has been observed while conducting examinations in an emergency psychiatric service that a large number of patients brought for evaluation had decompensated while at the airport. The purpose of this paper is to understand the acute psychiatric disturbance in terms of its occurrence at an airport. In order to more clearly delineate this group of patients, they were studied in respect to total number, age, diagnostic category, and stage in trip when they were referred for psychiatric observation. The study was conducted at Queens Hospital Center, which is a municipal hospital receiving about 3000 emergency room psychiatric visits yearly. Kennedy International Airport is included in the catchment area of the hospital and receives and funnels all patients to the Queens Hospital emergency room.In 1968, Miller and Zarcone¹ reported, in a retrospective study over 7 years, 49 patients who had been referred for psychiatric observation from San Francisco International Airport. They speculated that some of these patients probably showed symptoms of paranoia, anxiety, or euphoria prior to their arrival at the airport. Cheng and Hung,² in describing their experience at Taipei International Airport over a 3-year period, had 10 patients referred to their psychiatry facility as a result of disturbances sufficiently great to warrant removal from air flight. There are multiple reports in the literature of patients with severe phobic anxiety relating to flight,^3,4 as well as excellent studies describing people in transit^5,6 or air flight who become incapacitated temporarily as a result of the jet lag phenomena, culture shock,⁷ or actual crisis^8,9 in the course of their travel.     

Evaluation of psychiatric training in the emergency room

Records of 233 patients evaluated by psychiatric residents in the Emergency Room and subsequently reevaluated by senior psychiatrists in the Acute Treatment Clinic were examined for gross discrepancies in diagnosis, mental status, prescribed medication, and appropriate disposition of outpatients to a crisis clinic. The work in the Emergency Room was rated satisfactory in 90% of the cases. Length of training heightened the agreement between residents and senior staff on the mental status examination, the diagnosis and, to a lesser extent, the medication. There was no relationship between length of training and the agreement about the disposition. This was probably due to the lack of follow-up of the patients by the residents who had seen them in the Emergency Room. It was concluded that for optimal training purposes the Emergency Room experience should be combined with work in a crisis clinic where residents continue to treat patients whom they have referred from the Emergency Room.     

Treating insomnia: A practical guide for managing chronic sleeplessness,circa 1975

Insomnia means a complaint of sleep loss. Between 13% and 32% of surveyed populations suffer frequent insomnia,^1–3 and 7%–10% of the population use sleeping pills.^4,5 Alcohol and minor tranquilizers are also used to ease insomnia. The ubiquity of such drugs and the persistence of insomnia suggest that drugs alone do not remedy insomnia. The possibility of drug habituation, the distortion of sleep patterns, morning hangovers,^6,7 the possible accumulation of long-lived metabolites,⁸ and the risk of aggravated sleep disturbances upon withdrawal from sleeping pills^9,10 further complicate the use of hypnotics.Presently, there are few clinics offering specialized services for the treatment of sleep disorders. The physician is compelled to treat severe cases of insomnia and yet may feel that there is little to offer the insomnia patient besides hypnotic drugs. Some physicians, however, rarely prescribe sleeping pills for insomnia.^11,12 This paper, therefore, will offer practical suggestions on insomnia management, many of which do not depend primarily on the use of hypnotic drugs.     

The threatened staff: A psychoanalytic contribution to medical psychology

Hospital staff working with severely damaged physically handicapped patients are subject to more frequent and more intense personal distress than is a staff treating less seriously ill patients. Patients suffering from massive life-threatening, life-altering disease processes affect those who care for them in two ways: 1) by the sheer burden of their special emotional and physical demands; 2) through the conscious and unconscious fantasies stirred in the minds of staff members, by the stimulation of such damaging lesions.Evidence is presented from the data of staff member's everyday patient complaints. by organizing such complaints into three differing groups of staff-patient transactions, a previously unrecognized source of anxiety becomes evident: narcissistic vulnerability. This essentially normal, universally present, personality constellation (narcissistic vulnerability) is the area of staff member's psyche most threatened with disruptive overstimulation through work with this papient group.Implications of this hypothesis for the psychiatric consult's roles in staff education and patient service are explored.     

Patients' and therapists' expectations and evaluations of hospital treatment: Satisfactions and disappointments

Patients' and therapists' views of 14 treatment modalities were obtained at the beginning and end of treatment. Comparison across groups indicated that patients rated the modalities more favorably than therapists at both time points. Comparison of admission and discharge ratings within groups indicated that patients' expectations for the modalities were generally met, whereas therapists' expectations, particularly for the primary treatment modalities, were not met. Further, both patients and therapists were satisfied with the restful aspects of hospitalization and viewed them as having been as helpful as the primary treatment modalities.