The interface of psychiatric disorders and diabetes mellitus.

This paper reviews recent developments at the interface between psychiatric disorders and diabetes mellitus. A Medline search for the interval 1994 to 2000 was conducted, and the review addresses selected content from the search involving the following: 1) neuroleptic induced diabetes and the associated issue of diabetes and schizophrenia; 2) developments concerning various facets of the relationship of diabetes mellitus and depressive disorder; and 3) recent findings with regard to specific diabetic complications and their links to psychiatry.

The effect of the Utah Prepaid Mental Health Plan on structure, process, and outcomes of care.

Capitation reduced Medicaid costs but had limited effects on most measures of process and outcome. Clients under capitation with the poorest mental health at baseline performed more poorly over time on some measures.

Changes in the process of care for Medicaid patients with schizophrenia in Utah's Prepaid Mental Health Plan.

OBJECTIVE: Changes in the process of psychiatric care received by Medicaid beneficiaries with schizophrenia were examined after the introduction of capitated payments for enrollees of some community mental health centers (CMHCs) under the Utah Prepaid Mental Health Plan. METHODS: Data from the medical records of 200 patients receiving care in CMHCs participating in the prepaid plan were compared with data from the records of 200 patients in nonparticipating CMHCs, which remained in a fee-for-service reimbursement arrangement. Using the Process of Care Review Form, trained abstracters gathered data characterizing general patient management, social support, medication management, and medical management before implementation of the plan in 1990 and for three follow-up years. Using regression techniques, differences in the adjusted changes between third-year follow-up and baseline were examined by treatment site. RESULTS: By year 3 at the CMHCs participating in the plan, psychotherapy visits decreased, the probability of a patient's terminating treatment or being lost to follow-up increased, the probability of having a case manager increased, the probability of a crisis visit decreased (but still exceeded that at the nonplan sites), and the probability of treatment for a month or longer with a suboptimal dosage of antipsychotic medication increased. Only modest changes in the process of care were observed at the nonplan CMHCs. CONCLUSIONS: Change in the process of psychiatric care was more evident at the sites participating in the plan, where traditional therapeutic encounters were de-emphasized in response to capitation. The array of changes raises questions about the vigor of care provided to a highly vulnerable group of patients.

An instrument to evaluate the process of psychiatric care in ambulatory settings.

As part of an evaluation of the Utah Prepaid Mental Health Plan, the Process of Care Review Form was developed to assess the quality of the process of psychiatric care provided by Utah's community mental health centers (CMHCs) to clients with schizophrenia. This article briefly reviews issues in the measurement of quality of care and describes the development and implementation of the form. The 67-item form was designed for use by a trained abstracter to gather data from CMHC medical records in six areas: general management of the patient, medication management, medical management, social support, psychiatric hospitalization, and psychiatric assessment. A 59-item version of the form that omits the section on psychiatric assessment has been used in three waves of data collection to document data spanning five years (1990-1994) in the evaluation of the process of psychiatric care in the Utah plan. It is currently being used longitudinally to examine differences between Utah CMHCs receiving capitated payments and those paid on a fee-for-service basis by Medicaid.

Psychiatric diagnosis and the surgical outcome of pancreas transplantation in patients with type I diabetes mellitus.

To examine the role of psychiatric diagnosis in the surgical outcome of pancreas transplantation, we studied candidates with type I diabetes mellitus. Eighty of 140 candidates underwent transplantation. Survival analysis found the extent of human leukocyte antigen-DR (HLA-DR) matching, two diagnoses, and patients' perceived support from first-degree relatives to be related to duration of full-graft function. Lifetime diagnoses of tobacco use disorder (P = 0.029) and alcohol abuse/dependence (P = 0.006) were associated with less favorable outcomes; perceived support was associated with positive outcomes (P = 0.048). Subsequent analysis suggested that the four variables independently and directly affect outcome.

Clozapine-induced agranulocytosis in a Native American: HLA typing and further support for an immune-mediated mechanism.

BACKGROUND: Approximately 30% of schizophrenic patients defined as treatment refractory significantly improve with clozapine. However, clozapine produces agranulocytosis in approximately 1% to 2% of patients in the United States. The mechanism of clozapine-induced agranulocytosis has not been established, but evidence suggests an immune-mediated mechanism. METHOD: Human leukocyte antigen (HLA) typing was performed in a native American with clozapine-induced agranulocytosis. RESULTS: Our findings support previous observations of a role of the HLA-B16, DR4, DQw3 haplotype in predicting susceptibility to agranulocytosis in clozapine-treated patients. CONCLUSION: We suggest that HLA typing of clozapine candidates may be useful for predicting the risk for clozapine-induced agranulocytosis.

Does capitation affect the health of the chronically mentally ill? Results from a randomized trial.

OBJECTIVE: To determine the effect on health outcomes of enrollment of chronically mentally ill Medicaid recipients in prepaid plans vs traditional fee-for-service Medicaid. DESIGN: A randomized controlled trial. Clients who were randomly assigned to prepaid care were then permitted to choose among four capitated health plans. Clients returned to fee-for-service care at the end of the demonstration. SETTING: The Medicaid Demonstration Project in Hennepin County, Minnesota, the urban center of which is Minneapolis. PATIENTS: Seven hundred thirty-nine Medicaid clients who were classified as having chronic mental illness on the basis of Medicaid claims. Clients were interviewed at baseline (time 1) and at two follow-up points. Data were available for 96% of participants at the end of the intervention (time 2). Average duration of follow-up was 11 months. A subset of 370 clients with schizophrenia was followed up 11 months after the return of the prepaid group to fee-for-service care (time 3). MAIN OUTCOME MEASURES: General health status, physical functioning, social functioning, and psychiatric symptoms, assessed using the Schedule of Affective Disorders and Schizophrenia-Change version, the Global Assessment Scale, and indicators of community function. RESULTS: No significant differences between prepaid and fee-for-service groups in general health or psychiatric symptoms from baseline to time 2. After regression adjustment, 12% fewer clients in the prepaid group reported being victimized (P less than .01). At the end of time 3, the regression-adjusted Global Assessment Scale scores had worsened by 7.6 points more in the prepaid group in comparison with the fee-for-service group (P less than .02). CONCLUSION: There was no consistent evidence of harmful effects of enrolling chronically mentally ill Medicaid clients in prepaid care, at least in the short run. The generalizability of these findings may be limited to plans that control utilization by methods similar to those used in this study setting. Longer-term outcome studies should be undertaken to clarify the strength of the findings.

Lifetime prevalence of psychiatric disorders in patients with alopecia areata.

Thirty-one patients with alopecia areata were administered a structured psychiatric interview (the Diagnostic Interview Schedule; DIS). Overall, 74% had one or more lifetime psychiatric diagnoses. Particularly noteworthy were the high lifetime prevalence rates of major depression (39%) and generalized anxiety disorder (39%). In addition, patients reported increased rates of psychiatric disorders in first-degree relatives: anxiety disorders (58%), affective disorders (35%), and substance use disorders (35%). Patients with patchy alopecia areata were more likely to have a diagnosis of generalized anxiety disorder. No relationships were found between major depression and any variable characterizing alopecia areata history. Possible interrelationships between psychiatric disorders and alopecia areata are discussed. The study suggests that patients with alopecia areata are at increased risk for psychiatric disorders, and calls attention to the need for psychiatric assessment in this population.

Lithium treatment of chronic hair pulling.

Ten patients with chronic hair pulling received trials of lithium carbonate of 2 to 14 months' duration. Eight patients demonstrated decreased hair pulling and mild to marked hair regrowth. Three responders experienced increased hair pulling subsequent to discontinuation of lithium treatment. Lithium's effect on hair pulling may be related to its observed benefits in treating aggressivity, impulsivity, and mood instability.

Depressed mood and other variables related to bone marrow transplantation survival in acute leukemia.

Routine psychiatric evaluations of 100 adult patients undergoing allogeneic bone marrow transplantation for acute leukemia were reviewed to examine the possible relationship of psychiatric and psychosocial factors to duration of survival following the procedure. Three variables were found to independently affect outcome: illness status (first remission vs. other status), presence of depressed mood, and the extent of perceived social support. Patients transplanted while in their first remission had significantly improved survival; patients with depressed mood, regardless of specific psychiatric diagnosis, had poorer outcomes; and patients with a high level of perceived social support had improved survival. The possible mechanisms by which these variables affect outcome are discussed.

Adjustment disorders in medically ill inpatients referred for consultation in a university hospital.

The study examined medical records of 121 medical-surgical inpatients diagnosed with adjustment disorder by psychiatric consultants in a university hospital. Medical illness was the primary stressor, evoking the maladaptive reaction in 83 (68.6%) cases. These patients were largely free of preceding psychiatric problems, suffering protracted hospitalizations for advanced illnesses, particularly malignancy and diabetes; in contrast, the 38 (31.4%) patients whose adjustment disorder was precipitated by a stressor other than medical illness had established psychiatric histories and recurrent problems with relationships or finances. The data suggest that in the medically ill, identifying the primary stressor producing an adjustment disorder is more instructive than focusing upon "predominant" symptomatology and "subtypes."

Non-erotic self-choking in five psychiatric inpatients.

Recurrent self-choking without suicidal intent has received limited attention in the literature; most reports have focused on the sexual nature of the behavior. The authors describe five psychiatric inpatients who engaged in repeated non-erotic self-choking. Similarities in clinical features of the cases include a history of substance abuse (including abuse of volatile substances), aggressive behaviors, a chronic history of psychotic symptoms leading to repeated long-term hospitalizations, and a sense of relief or pleasure, but no overt sexual stimulation, caused by self-choking. The possible role of limbic system dysfunction in this behavior is considered.

Mitral valve prolapse and anxiety disorders in patients with anorexia nervosa.

Much has been written about the occurrence of mitral valve prolapse among eating disordered patients. Despite this literature, a causal relationship between the two conditions has yet to be established. The present study evaluated 500 patients with eating disorders and demonstrated an association between a low median ideal body weight and the frequency of mitral valve prolapse (P less than 0.001). The physical signs and symptoms of mitral valve prolapse disappeared in eating disordered patients with the return of normal weight (P less than 0.001). Contrary to prior reports, there was no association between mitral valve prolapse and the occurrence of diagnosable panic or anxiety disorders. The results of this study suggest that the symptoms of anxiety and panic associated with mitral valve prolapse in eating disordered individuals may be due to physiologic change in cardiac status related to weight rather than central nervous system changes associated with classic anxiety disorders.