Managed care and the future of psychiatry.

In 1987, one of us (T.D.) issued 3 predictions about the future of psychiatry, all of which have come true: (1) The promiscuous use of psychiatry to address a world of problems that are not biomedical and are unrelated to individual patients or their families has diluted the specialty's focus and made it what it should not be-a proposed solution to social ills. (2) The routinization of complex clinical tasks has inevitably resulted in downward decentralization, enabling lower-level professionals to take over responsibilities that were once the purview of physicians. (3) New knowledge about the brain and the mind have made it mandatory for psychiatry and neurology to mate for life to assure the future of both.

Transforming the present--discovering the future: the University of Pittsburgh's NLM grant on education and training of health sciences librarians.

BACKGROUND: The University of Pittsburgh was awarded a grant by the National Library of Medicine to study the education and training needs of present and future medical librarians and health information specialists through a collaboration of the university's School of Information Sciences and Health Sciences Library System. Goals and objectives for the year-long project included (1) assessment of education and training needs of medical librarians, (2) development of a master of library science curriculum and an internship program that would prepare graduates to take leadership roles in medical librarianship or information management, (3) development of continuing education programs for medical librarians in different formats, and (4) development of targeted recruitment efforts to attract minority group members and individuals with undergraduate science majors. The importance of this project, present practice, and success factors for programs seeking excellence in the preparation of health sciences information professionals are reviewed. A needs assessment involving a national advisory panel and a follow-up study of individuals who have participated in previous specialized training programs in health sciences information, compared with a peer group of medical librarians who did not participate in such programs, is described. This paper presents the goals and objectives of the project, describes the methods used, and outlines a curriculum, continuing education initiatives, and recruitment activities.

A cost-containment agenda for academic health centers.

Many people, particularly the business leaders and legislators who must find ways to pay most of the nation's health care bill, consider current and projected rates of health expenditure growth a serious problem. Effective solutions to this intractable problem have thus far eluded policymakers. The problem has complex and intertwined roots; its amelioration will require action by many players in the health sector. Academic health centers (AHCs), as the breeding ground for so much of the technological and organizational base of medical care and as the training ground for so many of the professionals in the health sector, bear some of the responsibility for the rate of health expenditure growth. Thus, they have a clear responsibility to help develop an effective response to this vexatious challenge. Three specific recommendations for steps the leaders of AHCs can take to assist in slowing the rate of growth in health care expenditures form the basis for this article.

The current status and future of VA research.

The VA Advisory Committee for Health Research Policy concluded that the health research aspect of departmental operations is vital to the VA's continued ability to provide high-quality health and medical care. The quality of VA-sponsored research in all areas remains high and on a par with that supported by the NIH and other governmental agencies sponsoring health research. Recent decreases in the financial support of VA research, however, have led to the unwise curtailment of VACO research staff support for this program, have reduced the number of approved projects that can be funded (though there has been a fourfold increase in the number of approved but unfunded projects), and are likely to reduce the attractiveness of VA employment for highly qualified physicians. In view of these findings, the committee recommended several steps that, if found feasible and taken soon, would both restore the long-standing stature of VA research and assure the attractiveness of VA careers for the many clinician-investigators upon whom the VA's quality of patient care necessarily depends.

The future of psychiatry.

The author reviews the vicissitudes of psychiatry's history over the past 50 years and urges the profession to abandon false boundaries between mind and brain and to make a commitment to the scientific validation of prevailing theories of the etiology of psychiatric disorders. He argues that the separation of psychiatry and neurology is no longer justified. He calls instead for a carefully conceived new career path leading to specialization in clinical neuroscience and further urges that psychiatric training programs be restructured to focus on the critical examination of problem solving and validation methods.

Management of the Menopause.

Menopause is merely a clinically discernible clue symbolic of the multitude of changes preceding or following the cessation of menses by many years. Because of the time span involved, separating changes observed in the menopausal transition from other age-related maturational events presents serious methodologic problems. Of the host of psychologic and psychosomatic symptoms, only hot flushes and associated sweats occur more frequently in this epoch, while an interplay between hormonal and age-related maturational events presents serious methodologic problems. Of the host of psychologic and psychosomatic symptoms, only hot flushes and associated sweats occur more frequently in this epoch, while an interplay between hormonal and age-related effects is assumed in atrophic changes involving the genitourinary organs. The relation between menopause and osteoporosis is suggestive but by no means proven, as is the risk for cardiovascular disease. Empiric evidence points to the usefullness of estrogen for the management of vasomotor instability, the symptoms associated with atrophy of the genitourinary tract, and in the prophylaxis of osteoporosis, but not in the treatment of anxiety, depression, and other psychiatric disorders.

Thiazide-lithium synergy in refractory mood swings.

The unfortunate experience with lithium chloride as a salt substitute in the 1940s still directs the clinical usuage of lithium carbonate to a certain extent. We are still warned that lithium salts should never be used in low-sodium situations (e.g., with thiazide diuretics or salt-restricted diets); however, it has recently been shown that thiazide diuretics may be safely used in the treatment of lithium-induced nephrogenic diabetes insipidus (NDI). The authors recapitulate the dangers inherent in the use of this drug combination and present detailed clinical-pharmacologic data on 13 patients which suggest that thiazides are useful in the treatment of lithium-induced NDI and may actually synergize with lithium to produce improved mood control in some lithium-refractory manic-depressive patients.

Incidence and signficiance of mixed affective states in a bipolar population.

The simultaneous existence of manic and depressive symptoms in a manic-depressive patient was first described by Kraepelin. This so-called mixed state has come to have much theoretical significance in recent hypotheses about the nature of bipolar affective disorders. In this investigation a mixed state is shown to be the initial episode in 31% of 84 manic-depressive outpatients. Moreover, the presence of "mixed" features does not correlate with severity of illness or mood circularity, but does correlate with sedative abuse and poor response to psychopharmacologic treatment. These results suggest that the "continuum hypothesis" and its satellite theories represent viable conceptualizations of the nature of manic-depressive illness.

Psychotic reactions associated with childbirth.

The literature on postpartum psychoses is reviewed. Clinical similarities and differences between patients with postpartum psychoses and those with nonpuerperal psychoses are described. The psychological and physiological precipitants of postpartum psychoses are discussed and a stress summation theory is proposed to explain the etiology of these reactions. Treatment considerations and factors pointing to favorable short-term and long-term prognoses are reviewed.

Are there two types of unipolar depression?

Personality traits and clinical characteristics in psychiatric outpatients with affective disorder were examined. Two groups of unipolar patients, divided on the basis of treatment response to tricyclic antidepressants, were compared to a bipolar group. While the unipolar-T (tricyclic responder) group showed premorbid personality traits of chronic anxiety and obsessiveness, neither the bipolar nor unipolar-L (tricyclic nonresponder, lithium carbonate responder) groups showed such findings. In fact, the unipolar-L and bipolar groups were similar not only with regard to personality variables, but also in terms of both drug response and certain family history features. These findings cast doubt on the homogeneity of unipolar depression and suggest the possibility of a subtype of unipolar depression with psychobiologic and personality features resembling bipolar disorder.

Psychopharmacologic management of patients: a method for recording treatment decisions.

The authors describe a drug treatment form they designed, the KDS-8, that is suitable for use in all types of treatment settings. An important feature is a checklist of treatable target symptoms, with categories of improvement, no change, or worsening. Changes in drug regimen and the clinician's reasons for them are noted. Among the advantages the authors cite are easy retrievability of drug treatment data and the forms suitability for use in audit procedures and research.

Sleep EEG and motor activity as indicators in affective states.

This report reviews a number of studies which support our current classification schema for affective disorders. This classification differentiates between an anxious-hyperactive type and an anergic-hypoactive type which are then further subdivided into primary and secondary affective disorders. While the motor and activity measurements are for the most part limited to patients suffering from primary affective disease, current studies under way indicate that secondary affective disorders may also have characteristic biologic changes. EEG sleep and motor activity parameters provide useful pointers for differential diagnosis and treatment while having the added advantage of diminishing the clinician's almost exclusive dependency on amnestic data and the psychological observations made on the patient's behavior.

Postpartum psychoses.

The authors describe clinical features of thirteen patients with postpartum psychoses and present data from a follow-up study with an average duration of six years. In particular, three patients are described who showed rapidly alternating manic and depressive symptoms. The theoretical and therapeutic implications of these findings are discussed.