Delusions: when to confront the facts of life

Research indicates that patients do not hold delusions with as fixed a certainty as has been believed. Confrontation with reality may have an important role in the evaluation and treatment of delusional patients. The authors suggest four factors that may help predict the value of reality confrontation in a given clinical situation: 1) how understandable the delusion is in the context of the patient's life, 2) the degree of conviction with which the patient holds the delusion, 3) the phase in development of the delusional beliefs, and 4) the diagnosis of the patient.

Coronary artery bypass in a patient on lithium carbonate prophylaxis

What is thought to be the first case of coronary artery bypass in a patient on lithium carbonate prophylaxis is presented. A postcardiotomy delirium developed on day 2 and appeared unrelated to the underlying manic-depressive illness. A 2-year follow-up indicated apparent resolution of pre-existing psychological difficulties and no recurrence of somatic symptoms. It is suggested that lithium carbonate prophylaxis be continued with appropriate monitoring during coronary artery bypass procedures.

Employment changes among patients following coronary bypass surgery: social, medical, and psychological correlates

The relations of socioeconomic and psychological factors to resumption of employment following coronary artery bypass surgery were studied using a questionnaire returned by a sample of 426 men and 70 women. The sample was drawn from the membership of Mended Hearts, Inc., a nationwide voluntary organization of persons who have had heart surgery. Preoperatively, more men (92 percent) than women (59 percent) were employed. Return to work rates were high for men (81 percent) and much lower for women (58 percent). The 395 men tended to return to work an average of 3.7 months after surgery whereas the 41 women took an average of 4.8 months. Return to work following surgery was most clearly related to socioeconomic level for both sexes. In addition, for men, those most likely to return had less postoperative morbidity and held jobs requiring little physical exertion. Patients who reported that they were forced into an early retirement represent a particularly vulnerable group in that they were more likely to experience the most postoperative morbidity. As a group, they believed that their physicians had least prepared them to return to work, and they experienced the poorest emotional adjustment. Thus, women and those forced into early retirement represent two potentially high-risk groups of patients who would seem to require additional clinical and psychological management following surgery.

Assessment of recovery: with special reference to a study with post-operative cardiac patients

The recovery process is dependent on many psychological and physical factors. In this paper recovery refers to major, short-term illness often treated by surgery, which is not expected to result in permanent disability or handicap. Research reviewed which attempts to identify influences on recovery also shows how many patients are left with a degree of disability, usually for psychological reasons. It is suggested that the stress and impact of severe illness and surgery may have a long lasting, previously unrecognized effect. Nursing which studies the interaction of physical and psychological aspects of illness and care is seen as the most suitable discipline from which to assess recovery and identify risk factors. A study reported here with patients after coronary artery grafting, provides information on recovery and illustrates how many aspects of a patients' experience may help or hinder this process. Data is obtained from patients' interviews to give a wider, more humanistic evaluation of outcome than is usually employed for this type of surgery.

Bipolar affective disorder following coronary bypass surgery

Bipolar affective disorders characterized by mania and depression have not previously been reported as a complication of coronary bypass surgery, although pure depressive symptoms are well known. This case describes a 46 year old male, with a negative psychiatric history, who developed mania as well as depression after having two vessel bypass surgery on his right coronary artery. The patient's history and symptoms of mania and depression met research criteria for the diagnosis of a bipolar affective disorder, and he responded well to lithium carbonate.

Individual differences in life-style response to coronary artery bypass surgery

Fifty-three patients who had undergone coronary artery bypass surgery 12 to 27 months previously were given four standard personality questionnaires and asked to write about the main effects the operation had on their life-styles. These responses were then content analysed. Although hierarchical grouping analysis indicated that the responses could best be classified into four groups, only three distinct response profiles emerged. The first group described mainly adverse consequences of surgery; the other three groups described the effects of surgery as beneficial. Personality test data suggested that individual personality and coping style considerably influence a patient's perception of surgical outcome, and that this perception is largely independent of cardiac symptoms.

Coronary artery bypass graft surgery: clinical decision making and cost-effectiveness analysis

Decision-analytic techniques were used to evaluate the choice between an aortocoronary bypass operation and medical management in a set of hypothetical patients with coronary artery disease. The decision framework incorporates variables believed to have an important bearing on the choice of treatment. Probability estimates were obtained from two cardiologists and one cardiac surgeon. Patient preferences for the trade-off between years of survival and the quality of life as reflected by the severity of angina pectoris were made explicit by assigning utility values to alternative health outcomes. The results are expressed in terms of quality-adjusted years of life expectancy. Decision analysis favored operation for 13 of the 14 hypothetical patients, including patients with one- and two-vessel disease. The one patient for whom medical treatment was preferred had mild angina pectoris, severe left ventricular dysfunction, and a poor prognosis regardless of therapeutic modality. The results are sensitive to changes in the probability of long-term survival, but not to changes in operative mortality rates. In five patients, the physicians' clinical judgments favored medical treatment, whereas their decision-analysis-derived estimates of survival favored operation. Possible explanations for these discrepancies are discussed. A simplified cost-effectiveness analysis for patients in whom surgery was the optimal treatment indicated costs ranging from $1,500 to $250,000 per year of life gained and from $1,500 to $32,000 per quality-adjusted year of life gained.

Psychosocial outcome after coronary artery surgery

To describe psychosocial adaptation after coronary artery surgery and to identify preoperative factors associated with good outcome, the authors interviewed 30 patients before and 1--2 years after surgery. Despite good physiologic outcome (as measured by treadmill and cardiac function) this sample was found to be functioning poorly. Eighty-three percent were unemployed, and 57% were sexually impaired. A preoperative duration of symptoms of eight months or more was associated with significantly worse postoperative overall adaptation. Most patients who had suffered angina eight months or longer evidenced a damaged self-concept, which was reinforced rather than repaired by the experience of surgery.

The psychodynamic impact of coronary bypass surgery

Twenty-one individuals underwent extensive psychological evaluation before, and four months after, coronary bypass surgery, that examined: defensive mechanisms; fantasies and distortions; subjective meaning of the procedure; and transference and projections. Patients showed a significant improvement in their physical condition and indicated vigorous psychodynamic activity. Both before and after surgery many patients: a) used denial; b) misconceived the procedure; c) developed a subjective explanation of etiology; d) mourned; and e) revered their surgeon. Following surgery, many patients: a) rationalized their decision; b) reviewed their life and changed priorities (valuing human closeness, devaluing work); and c) recognized their mortality (engendering a renewed interest in life and/or rage).