Somatic symptom reporting in women and men.

Women report more intense, more numerous, and more frequent bodily symptoms than men. This difference appears in samples of medical patients and in community samples, whether or not gynecologic and reproductive symptoms are excluded, and whether all bodily symptoms or only those which are medically unexplained are examined. More limited, but suggestive, literature on experimental pain, symptom reporting in childhood, and pain thresholds in animals are compatible with these findings in adults. A number of contributory factors have been implicated, supported by varying degrees of evidence. These include innate differences in somatic and visceral perception; differences in symptom labeling, description, and reporting; the socialization process, which leads to differences in the readiness to acknowledge and disclose discomfort; a sex differential in the incidence of abuse and violence; sex differences in the prevalence of anxiety and depressive disorders; and gender bias in research and in clinical practice. General internists need to keep these factors in mind in obtaining the clinical history, understanding the meaning and significance that symptoms hold for each patient, and providing symptom relief.

Psychiatric symptoms and medical utilization in primary care patients.

In two studies, the authors evaluated the impact of psychiatric disorders on medical care utilization in a primary care setting. In the first study, 526 consecutive patients in a teaching hospital primary care practice completed the 18-item RAND Mental Health Inventory to identify clinically significant depression and/or anxiety and a questionnaire about the use of psychiatric treatment and psychoactive medications. The medical utilization of those patients defined as depressed and/ or anxious was compared with those defined as not depressed and/or anxious. Patients identified as depressed and/or anxious reported significantly increased medical utilization, but this was not confirmed by the hospital's computerized record system. In the second study, the authors analyzed medical care utilization for the years before and after the first outpatient psychiatry appointment of a sample of 91 patients referred from the same primary care practice to the hospital's outpatient psychiatry clinic over a 1-year period. In both studies there was not a statistically significant difference in medical utilization among those patients receiving psychiatric treatment. The findings demonstrate the difficulties in examining cost offset in a primary care population and raise questions about it as a realistic outcome measure of the effect of psychiatric treatment.

Functional somatic syndromes.

The term functional somatic syndrome has been applied to several related syndromes characterized more by symptoms, suffering, and disability than by consistently demonstrable tissue abnormality. These syndromes include multiple chemical sensitivity, the sick building syndrome, repetition stress injury, the side effects of silicone breast implants, the Gulf War syndrome, chronic whiplash, the chronic fatigue syndrome, the irritable bowel syndrome, and fibromyalgia. Patients with functional somatic syndromes have explicit and highly elaborated self-diagnoses, and their symptoms are often refractory to reassurance, explanation, and standard treatment of symptoms. They share similar phenomenologies, high rates of co-occurrence, similar epidemiologic characteristics, and higher-than-expected prevalences of psychiatric comorbidity. Although discrete pathophysiologic causes may ultimately be found in some patients with functional somatic syndromes, the suffering of these patients is exacerbated by a self-perpetuating, self-validating cycle in which common, endemic, somatic symptoms are incorrectly attributed to serious abnormality, reinforcing the patient's belief that he or she has a serious disease. Four psychosocial factors propel this cycle of symptom amplification: the belief that one has a serious disease; the expectation that one's condition is likely to worsen; the "sick role," including the effects of litigation and compensation; and the alarming portrayal of the condition as catastrophic and disabling. The climate surrounding functional somatic syndromes includes sensationalized media coverage, profound suspicion of medical expertise and physicians, the mobilization of parties with a vested self-interest in the status of functional somatic syndromes, litigation, and a clinical approach that overemphasizes the biomedical and ignores psychosocial factors. All of these influences exacerbate and perpetuate the somatic distress of patients with functional somatic syndromes, heighten their fears and pessimistic expectations, prolong their disability, and reinforce their sick role. A six-step strategy for helping patients with functional somatic syndromes is presented here.

Somatization and medicalization in the era of managed care.

Somatization, the reporting of somatic symptoms that have no pathophysiological explanation, appears to be increasing as sociocultural currents reduce the public's tolerance of mild symptoms and benign infirmities and lower the threshold for seeking medical attention for such complaints. These trends coincide with a progressive medicalization of physical distress in which uncomfortable bodily states and isolated symptoms are reclassified as diseases for which medical treatment is sought. Somatization and medicalization are likely to become more problematic in the era of managed care. Under capitation, providers will have greater incentives to reduce utilization, and somatizing patients may feel forced to express their "disease" in more urgent and exaggerated terms in order to gain access to the physician. In addition, prepaid subscribers will suffer little financial disincentive to seek medical attention for relatively minor complaints; therefore, they are likely to increase the demand for physician consultation. This situation suggests an urgent need to improve the management of somatizing patients. Innovative consultative, behavioral, and educational interventions are now available. In addition, medical professionals should greet the process of medicalization with considerable caution and educate the public more about the normative presence of symptoms and bodily distress in healthy people. Additional research is needed into somatization and its relationship to the demand for medical care. In an era of managed care, increased attention should be devoted to understanding and controlling the demand for care, a large portion of which is symptom driven.

Long-term outcome of state hospital patients discharged into structured community residential settings.

OBJECTIVE: This longitudinal study examined various dimensions of the lives of patients with chronic mental illness immediately before and again several years after their discharge from a state hospital into well-staffed structured community residential settings. METHODS: Fifty-three patients with chronic mental illness and long histories of hospitalization were evaluated shortly before their state hospital discharge using a comprehensive structured assessment of nine dimensions of functioning and symptomatology. A follow-up assessment was undertaken a mean of 7.5 years after discharge into four structured group home settings. RESULTS: At follow-up, 57 percent of the patients continued to live in structured community residential settings, 28 percent had moved on to independent living, and 16 percent had returned to an institutional setting. Fifty-five percent needed hospital readmission, but the total sample spent only 11 percent of the time after discharge in the hospital. At follow-up, patients showed significant improvements in cognitive and social functioning, and 94 percent expressed a preference for life in the community. CONCLUSIONS: Many patients discharged to structured community residential settings seem to prefer them to the state hospital, are able to graduate to independent settings, and show improvement in important dimensions of functioning after several years in the community. Other dimensions seem resistant to change despite the structure and support afforded by residential settings.

Economics and psychiatric education: the irresistible force meets the moveable object.

Recent changes in health care delivery and financing threaten the traditional funding base for psychiatric education. These changes are disrupting the often-tenuous "critical balances" in psychiatry residency, weighting them toward greater provision of services and less training, education, autonomy of practice, and time for personal needs. Three strategies for adapting creatively to the new fiscal and organizational realities in health care are described: decreasing the number of residents and residency-training programs, rethinking the content of residency so that it provides training for the practice realities of the twenty-first century, and marketing the quality and cost-effectiveness of academic psychiatry systems better in a managed care environment.

Teaching and learning psychiatry.

This article reviews the teaching-learning process in psychiatry. It describes eight attributes of a successful teacher, suggests ways that psychiatrists may improve their teaching skills, and delineates four stages (exposure, incorporation, integration, and mastery) of the learning process that have implications for how and what we teach. Methods to evaluate teaching rigorously so that it can be academically rewarded are described. At a time when the place of the psychiatric teacher in the academic medical center is precarious and often discouraging, the author discusses sources of support from students, fellow faculty, and national colleagues that can help sustain teaching in, and teachers of, psychiatry.

Teaching psychiatric residents to teach.

Teaching other residents and medical students is one of the primary activities of psychiatric residents, yet most receive minimal or no formal training or supervision on how to teach. This report describes a Teaching Day Workshop, designed and implemented by residents at the Massachusetts General Hospital with the support of their faculty and an educational consultant, as one model to introduce the concepts and techniques of teaching to psychiatric residents. The participating residents were unanimous in their positive appraisal of the workshop, and they recommended that additional seminars on teaching be integrated into the residency's core curriculum. Ways that the Teaching Day Workshop can be adapted for use by other residency training programs are discussed. The authors believe that teaching residents to be better teachers can have an impact on recruitment of medical students into psychiatry and psychiatric residents into careers in academic psychiatry.

A survival guide for psychiatric residency training directors.

This paper catalogues the inevitable problems that beset training directors and describes coping strategies designed to improve the likelihood of the training director's survival and the quality of his or her life. The difficulties of the job include picking residents, struggling to assure that the faculty provides decent teaching programs, contending with repetitive bureaucratic details, being overloaded by numerous tasks, and warily watching as residents who somehow squeaked through the program are sent off on their own. Offsetting the hassles are the exciting jobs of picking residents, guiding the faculty in setting up teaching programs, keeping a complicated program running, mastering numerous challenges, and watching with satisfaction as new, competent psychiatrists graduate.

Child psychiatry fellowship training: a crisis in recruitment and manpower.

Eighty-three percent (104 of 126) of the accredited child psychiatry fellowships in the United States responded to a survey of current manpower and training problems facing child psychiatry. Thirty-five percent of the respondents were having trouble filling their classes with highly qualified fellows, and 45% were having difficulty recruiting faculty child psychiatrists. Other significant problems included developing faculty interest in research, providing didactic seminars in new areas such as developmental neurobiology and infant psychiatry, and funding fellow and faculty positions and research. The authors examine this crisis in manpower, recruitment, and training and suggest solutions on local and national levels.

Looking back, moving ahead.

This issue marks an important transition for Academic Psychiatry. As we assume editorship, we wish to acknowledge our debt and gratitude to the vision, persistence, and hard work of the journal's founding editor-in-chief, Dr. Zebulon Taintor.

Developing minimal national standards for clinical experience in psychiatric training.

There are no minimum standards for the clinical training of psychiatrists with regard to the type and number of patients evaluated or treated. Interest in establishing such standards derives from a need for greater accountability, a high fail rate on the clinical portion of the American Board of Psychiatry and Neurology examinations, and an increasing demand for precise documentation of competence in specific areas by hospital privileging committees. Although considerable disagreement exists as to what the overall requirements should be, some minimum requirements can be agreed on. The authors discuss concerns about minimal standards and make suggestions for further development of standards.

Primary health care providers' recognition and diagnosis of mental disorders in their patients.

Primary care physicians and nurse practitioners are the initial casefinders of mental health problems and major providers of mental health treatment in the United States. However, past studies suggest that such primary care providers often neither recognize nor correctly diagnose their patients' mental disorders. This study compared an HMO's primary providers' direct assessments of the current emotional disorders of patients just seen for an outpatient medical visit with those of mental health professionals assessing the same patients with the Structured Clinical Interview for DSM III R (SCID). Using the SCID-derived diagnosis as the standard, the primary providers failed to recognize almost two-thirds of their patients with a current mental disorder. Although confident in their assessments, the primary providers were also able to correctly identify very few of the specific mental disorders most prevalent in primary medical care practice; they identified only one of the seven depressions, three of the 18 anxiety disorders, and none of the four alcohol or drug abuse disorders. Reasons for these diagnostic discrepancies, comparisons with past studies, and training to improve primary providers' diagnosis of mental disorders in their patients are discussed.

[Identifying mental health service needs of persons with schizophrenia]. / Combler les besoins de services de santé mentale des personnes atteintes de schizophrénie.

The present study aimed to identify the needs and describe the use of twenty mental health services in a population of chronic schizophrenic patients living in two regions in Quebec (Estrie and Centre-Sud). An attempt was also made to determine the principal reasons for which some services were not being used when they were identified as clinically required. The population considered was composed of the patients (N = 88) who had been discharged from the psychiatric care units of five general hospitals over a period of five months in 1982, and for whom the attending psychiatrist could confirm with certainty a diagnosis of chronic schizophrenia in accordance with the criteria of DSM-III. Medical files of these patients were reviewed, and the patients and psychiatrists themselves were interviewed separately regarding the patients' needs and use of twenty mental health services over the period from the seventh to the twelfth month after discharge from hospital. Results of the study show that services which were most often identified as clinically required were: 1) taking of neuroleptics, 2) organization of leisure activities, 3) case management, and 4) individual supportive therapy. At the same time, results indicate a poor fit between needs and use for most of rehabilitation and psychosocial services. The main reasons for non-use of services which were identified as clinically required are also presented. The implications of these results for the organization of mental health services for persons suffering from chronic schizophrenia are discussed, especially the importance of case management services.

Are we training too many psychiatrists?

In contrast to the past decade's concerns about an undersupply of psychiatric manpower, the authors point out that the profession may soon be facing the prospect of an oversupply of psychiatrists. Given the present rate of producing psychiatrists, shifts in demands for psychiatric services, changing payment and access patterns regarding specialty medical care, increasing numbers of nonpsychiatrist mental health professionals, and a probable surfeit of primary care physicians, underemployment of psychiatrists may become commonplace. Future psychiatrists will likely be used more as consultants, and the profession will need fewer, but better trained, graduates. The authors present alternative proposals to deal with service needs related to such reductions.