A liaison fellowship on a hemodialysis unit. A self-funded position

The practice of liaison psychiatry has from its inception been hampered by an inadequate or non-existing funding base. A model is presented for funding an authentic liaison training program, fully supported by consultation-generated revenue. A specific description of the liaison teaching unit is given, which illustrates how the following objectives of the program were successfully met: provision of comprehensive biopsychosocial care, dissemination of psychological skills and knowledge to nonpsychiatrist staff, training of the liaison fellow, and generation of sufficient revenue to offset its costs.

Cortisol production in obesity

Absolute cortisol production was estimated from the urinary excretion of tetrahydro metabolites of cortisol in 74 healthy women varying in weight from 12% below to 218% above desirable weight, and in 37 healthy men varying in weight from 3% below to 139% above desirable weight, and was measured by isotope dilution (after 14C tracers) in 26 of the women and 23 of the men. The relationship of both parameters to urinary creatinine excretion (as a measure of lean body mass) and to percent deviation from desirable weight (relative weight) was determined. Both absolute cortisol production and urinary creatinine excretion showed a significant positive linear correlation with relative weight in the men and women, but cortisol production/g urinary creatinine excretion (by isotope dilution or by tetrahydro metabolite excretion) was weight-invariant in both sexes. The geometric mean of cortisol production/g creatinine was 12.9 mg/g in men and 14.5 mg/g in women; the difference was not statistically significant. The geometric mean of tetrahydro metabolite excretion/g creatinine was 3.7 mg/g in men and 3.8 mg/g in women; the difference was not statistically significant. The average ratio of cortisol production to tetrahydro metabolite excretion was 3.5 in men and 3.8 in women, values not significantly different from one another and closely confirming our previously reported value of 3.6, based on the conversion of cortisol tracers to radioactive urinary tetrahydro metabolites. It is concluded that there is no functionally significant elevation of cortisol production in obese men or women: the increase in absolute production is solely a consequence of greater lean body mass, and the production/U lean body mass is weight-invariant. It appears desirable to make any comparisons of one group of patients with another in terms of cortisol production/g urinary creatinine in order to eliminate body size and obesity as confounding factors, so that disease-related differences may emerge clearly.

Subnormal plasma adrenal androgen levels in men with uremia

The 24-h mean plasma concentrations of 8 hormones were measured in 11 men with chronic uremia and 32 normal men. Our findings confirm previous reports of subnormal levels of testosterone, T3, and T4 and elevated levels of LH, PRL, and cortisol. In addition, we observed a new finding: markedly subnormal levels of the adrenal androgens dehydroisoandrosterone (DHA) and DHA sulfate. The mean DHA level in the patients was 164 +/- 46 (SD) ng/dl, compared with 320 +/- 124 in age-matched controls (P < 0.0001); the geometric mean DHA sulfate level was 40 micrograms/dl (95% confidence limits, 11-113) in the patients and 76 micrograms/dl (95% confidence limits, 26-214) in age-matched controls (P = 0.005). The depression of adrenal androgen levels in the face of elevated cortisol levels suggests a biosynthetic block in the adrenal cortex at the step where the C-19 and C-21 pathways diverge, namely the removal of the 2-carbon side chain by C-17, 20-lyase. If a similar defect were present in the testes, it could account for the diminished synthesis of testosterone, which is a further metabolite of DHA in the testes.

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.

Detection of cognitive deficits by a brief mental status examination: the Cognitive Capacity Screening Examination, a reappraisal and a review

Results of a brief mental status questionnaire, the Cognitive Capacity Screening Examination (CCSE), were compared with the clinical evaluations of 59 patients on a neurology service. In 71% of the cases, the CCSE scores correctly indicated a cognitive deficit (true-positive) or the absence of one (true-negative); false-negative results were observed in 15% and questionable negative results were found in 10%. Abnormal neurologic physical signs were present in 90% of all patients with cognitive deficits. In this population, although positive CCSE scores were reliable, negative scores were often misleading. Mild diffuse intellectual dysfunction (dementia) and some discrete intellectual deficits (aphasia and anosognosia) went undetected. Cognitive deficits associated with major cerebral disease were unappreciated in nine patients. Caution is recommended in interpreting negative CCSE scores. Abbreviated screening devices are only a preliminary approach to mental status evaluation; this test requires further refinement.

The effects of a psychiatric liaison program on the utilization of psychiatric consultations: an evaluation by chart audit

The effects of a psychiatric liaison program were studied by a chart audit examination of psychiatric consultations on a medical service. A comparison of the full liaison ward with the other wards revealed significant differences in the use of emergency consultation and psychiatric follow-up treatment. The results indicated improved psychologic management of medical patients on wards with intense liaison involvement but no measurable change in attitude toward the psychiatrist. Evaluation methodology and implications of the results are discussed.

Recording psychiatric consultations: a preliminary report

Two new forms, specifically designed for computer processing of data from a contemporary consultation-liaison service, are described. The need for such data and their immediate applicability to problems currently facing this psychiatric subspecialty are discussed. Clinical, administrative, and evaluation uses are reviewed. It is hoped that this work will provide a stimulus to consultation-liason practitioners to use this system or to develop similar systems that will permit documentation, exploration, and enhancement of the consultation-liaison effort.

Psychological reactions to chronic medical illness

Psychological reactions to chronic medical illness can be categorized as follows: the chronically ill patient is vulnerable, first and foremost, to eight types of psychological stress, all of which have their roots in early childhood. Specifically, chronic illness evokes a threat to the patient's self esteem; fear of strangers; separation anxiety; fear of loss of love, and of the control of developmentally achieved functions; fear of loss of, or injury to body parts; guilt and fear of retaliation; and fear of pain, which cuts across all of these stresses. Other psychological reactions to chronic medical illness include regression, conflict, and inevitable distortions in object relationships. Suggestions for the amelioration of these responses within the matrix of the doctor patient relationship are proposed.

Psychological impediments to weight loss

An understanding of the possible psychologic impediments to weight loss can promote improved therapeutic intervention for the obese patient. Certain psychological tasks are imposed by chronic medical illness including obesity. The universal stresses that accompany medical illness, the basic threat to self-esteem and sense of intactness, the fear--of loss of love and approval, of loss of control of function, of injury to body parts, of pain, and of guilt--all become psychological impediments thwarting weight loss and its maintenance. The physician's awareness of these psychological stresses helps him identify areas of necessary support.

Ombudsmen (medical-psychiatric) rounds. An approach to meeting patient-staff needs

Ombudsmen rounds conducted jointly by a medical attending physician (ombudsman) and a psychiatrist bring the entire staff on each of the medical wards of Montefiore Hospital together weekly. An attempt is made to address both staff and patient needs on an inpatient medical service. Through group discussions and patient interviews, in which the patient has an opportunity to express his own feelings about his illness and his care, the staff becomes aware of the psychosocial issues that are universally evoked by illness and hospitalization. All staff members are also encouraged to relate their reactions to the patient and their interactions with each other. The ombudsmen-rounds concept maximizes the use of the internist and liaison psychiatrist, and makes psychosocial-medical teaching routine on the medical service in a contemporary teaching hospital where the practice of holistic medicine has been so difficult to implement.

The physician's knowledge of psychotropic drugs: preliminary results

A questionnaire about three commonly prescribed psychotropic drugs was administered to physicians and trainees in two specialties and to medical students. Psychiatrists and psychiatric residents had very low levels of knowledge about the physiology, pharmacology, and side effects of diazepam; their scores did not exceed those of medical residents or students. Trainees in internal medicine scored poorly regarding the diagnosis of depressive syndromes and the physiology and pharmacology of imipramine and amitriptyline, whereas psychiatrists performed well. The results of this preliminary study can provide guidelines for improving the teaching of psychopharmacology in general and the psychopharmacological treatment of the medically ill in particular.

Psychological reactions to acute medical illness and critical care

The psychological stresses evoked by acute critical illness and intensive care in both patient and physician are examined and certain approaches proposed which, in our experience, can alleviate these stresses. Admittedly, these psychological concepts may appear inconsequential at first glance. We have found, however, that such intervention may facilitate the physician's efforts to provide appropriate care for his critically ill patients, including those who must die, without experiencing the psychological reactions--the guilt, shame, anguish, and despair--these patients typically arouse.

The medical setting: is it beyond the psychiatrist?

Recent events in medicine have afforded psychiatrists an opportunity to move beyond the traditional boundaries of their involvement in the medical setting. The growing preoccupation of the medically ill and their families with the psychosocial aspects of medical illness, their growing dissatisfaction with current patterns of patient care, and internists' increased awareness of the psychological needs of the nonpsychiartic medical patient have led to a rethinking of mind-body dualism and to increased involvement of the psychiatrist in general medical care.

Screening for organic mental syndromes in the medically ill

A brief mental status questionnaire adapted specifically to diagnose diffuse organic diffuse organic mental syndromes on busy medical words is developed and tested for reliability and validity. When the 30-item questionnaire was given to 17 medical patients diagnosed by consultation spychiatrists as having a diffuse organic mental syndrome, all score 20 or less. With hospitalized psychiatric patients the questionnaire was able to differentiate between the "functional psychoses" and diffuse organic brain syndromes. When administered to 69 consecutive medical admissions, fully one third showed marked cognitive limitations. A sample of normals suggested that results may be contaminated by severe cultural or educational variances. We discuss the role of cognitive dificiencies in medical patients, and suggestions are made regarding the broad usefulness of this questionniare to a medical service.

Issues in the assessment of post-ECT memory changes

In this study memory changes during and after electroconvulsive therapy were investigated by means of three different tests. The investigation was double-blind and the subjects were 96 patients hospitalized with depressive illness. Amounts of post-ECT amnesia were evaluated in relation to number of treatments for symptom remission and stability of the therapeutic result over the period of one year.