Can the patient-physician relationship survive in the era of managed care?

The author discusses the history of the patient-physician relationship and considers how recent developments in the health care system have affected the viability of that relationship. He first considers the justification for maintaining such a relationship and concludes that the patient-physician relationship must be preserved because it has a long history, is humane and ethical, and is cost effective. The author then reviews the ethical basis that forms the foundation of the patient-physician relationship. He discusses issues related to competency, commitment, compassion, equanimity, and patient advocacy. The article concludes with a consideration of the medical-ethical dilemmas created in the patient-physician relationship by managed care.

Combining pharmacotherapy with psychotherapy in the treatment of anxiety disorder.

Anxiety disorders are more prevalent than any other mental health problem in the USA, but afflicted patients are often untreated or treated only by a primary care physician. Anxiety disorders can be understood in the context of the interplay of biological, psychosocial, and behavioral factors. Psychiatry has defined effective treatment that integrates education, psychotherapy and psychopharmacology. A combination of treatment approaches may be beneficial. Anxiety related symptoms, other than a true anxiety disorder, may be precipitated by normal stresses of daily life. These patients may also benefit from treatments used in anxiety disorders. Anxiety can also occur secondary to medical disorders and medications, as well as being present as part of other psychiatric syndromes. Diagnosis requires a history, physical examination and laboratory tests. Anxiety disorders, although common, are easily overlooked because patients may present with somatic complaints rather than admit to having emotional problems. Anxiety disorders are divided into seven categories in DSM IV, with each allowing for a differential treatment approach. Non-pharmacological treatments are the first line of treatment, and may include behavior therapy and cognitive therapy. The physician-patient relationship is itself a powerful treatment tool. Key areas in which the psychiatrist can help the patient cope are outlined. Benefits and risks of drug treatment for anxiety disorders are discussed.

Screening for anxiety disorders in the primary care setting.

It is important to identify patients with anxiety disorders in the primary care setting so that they may be appropriately treated. The authors propose administration of a brief, 40-item screening instrument, the Four Dimensional Anxiety Scale (FDAS), to distinguish anxiety disorders from anxiety associated with medical conditions and from normal anxiety. For anxiety disorders patients, responses to five items on the FDAS Emotional dimension and 10 items on the Cognitive dimension differ significantly from medical patients or normals, and may help identify them. With such early identification and referral, medical costs of inappropriate care can be minimized, and human suffering can be alleviated through referral to a specialty anxiety disorders clinic.

Critical review of psychosocial interventions in cancer care.

The need for a large variety of psychosocial interventions is enhanced as increasing numbers of patients with cancer have longer survival. This article reviews the four interventions used most commonly: (1) education, (2) behavioral training, (3) individual psychotherapy, and (4) group interventions. It examines the outcomes of each type of intervention. This comprehensive review of the intervention literature reveals the availability of a wide range of options for patients with cancer and their potential psychological and physical health benefits.

Mental health service for medical students.

The authors describe the problem of impairment of medical students from the point of view of mental health professionals who have directed a large and successful evaluation and referral service for students suffering from a wide array of stress-related and mental disorders. They outline the nature of the impairment problems, the history of the efforts at their medical school to address these problems, and their recent experience in providing mental health services to students who are referred for evaluation and treatment. Diagnostic data, referral and the implications of mental disorders for medical students are discussed. The authors offer some suggestions for the formation of student well-being committees prior to the implementation of student assistance programmes to address the problems of substance abuse.

Low dose desipramine treatment of cocaine-related panic attacks.

Thirteen patients meeting DSM-III-R criteria for panic disorder with or without agoraphobia that started during or shortly after cocaine exposure were treated in the UCLA Anxiety Disorders Program (Los Angeles, CA). Low starting doses (ranging from 2.5 to 10 mg/day) of desipramine were used. Doses were then slowly increased to an average daily dose of 25 mg. Eleven patients who were able to tolerate an initial increase in panic anxiety responded to this treatment strategy with almost full resolution of panic attacks. The authors discuss the possible value and mechanisms of low dose treatment of cocaine-related panic attacks.

Psychological reaction to hospitalization and illness in the emergency department.

Each personality type presents with different methods of coping. Physicians should be aware of the impact on a patient's psychological functioning and ability to cope with illness and hospitalization, to understand and more effectively manage the patient. The physician must try to assess the patient's baseline personality from their past and present behavior. Establishing a good physician-patient relationship is important as a source of information about behavior of patients and how they will respond to their illness. Depending on the specific personality type, each patient will respond differently to the stress of illness. The effort of the emergency physician to identify personality types will aid in medical management of the patient and enable the physician to help each patient cope effectively with the illness and the hospitalization. The specific issues that seem to be threatening to traumatized patients include the following: helplessness, humiliation, blurring of body image, and gaps in memory filled with distortions. The traumatized patient experiences an altered state of consciousness which is either due to a physiologic cause or an emotional cause. Emotional causes are usually based on defensive dissociation. People who have been in an auto accident characteristically report loss of memory of the intense pain that the accident produces initially. Oftentimes, the core experience for the traumatic patient is not somatic, it is unconscious. The interesting feature is that so many patients do not remember the accident. The mind seems to be filled with all kinds of distortions and irrelevant and perhaps totally inconsistent fantasies, such as imprisonment, confinement, or deathlike experiences. Some report that they are being incarcerated, others recall being in a featureless cubicle with no contact with the normal world in which there are no windows, no pictures, no flowers. Others remember only being surrounded by masked, hatted, uniformed wardens who are standing over them with nasogastric tubes, intravenous lines, Foley catheters, arterial blood gases, subclavians, and dermal cut-downs. This is an overwhelming nightmare that can be relieved only by the empathic and caring physician and emergency department staff. The stress of medical illness and/or hospitalization can be overwhelming for some patients and is usually followed by some form of psychological response. Current understanding of the psychological impact of illness is based upon psychological defenses, coping mechanisms, and individual personality. It is the ability of the emergency physician to identify defenses, coping skills and personality types that will aid him or her in the medical management of the patients in their time of illness and hospitalization.

An overview of anxiety disorders.

Anxiety disorders are more prevalent than any other mental health problem in the United States. Afflicted persons are often untreated or are treated only by a primary care physician without psychiatric consultation. However, based on current knowledge of the biological and psychological factors involved in these disorders, psychiatry has defined effective treatment that integrates education, psychotherapy, and psychopharmacology. After reviewing current research on possible mechanisms of anxiety, the authors discuss therapeutic interventions and recommend ways to choose appropriate treatment modalities for anxiety-disordered patients.

Darwin's illness: a biopsychosocial perspective.

Throughout an illustrious scientific career, Charles Robert Darwin (1809-1882) suffered from a mysterious and disabling malady. The illness, which was characterized by depressed feelings and violent and uncomfortable cardiac palpitations, gastric upsets, and headaches, began shortly after Darwin returned from a five-year voyage to South America as the naturalist of the Beagle. One explanation for Darwin's symptoms is he suffered from Chagas' disease as a result of being bitten by an insect common to South America. More psychodynamically oriented theorists speculate that Darwin's illness was an expression of repressed anger toward his father. Others have noted a familial vulnerability to the symptoms Darwin described. The author examines these theories and suggests that they all may have validity in explaining the mysterious illness of Charles Darwin.

Psychiatric syndromes linked to reproductive function in women: a review of current knowledge.

Four psychiatric syndromes related to reproductive function in women have been identified: postpartum depression, premenstrual syndrome (PMS), post-hysterectomy depression, and involutional melancholia. The authors review what is known about these syndromes and conclude, first, that postpartum depression comprises three separate syndromes, the most severe of which is most likely a variant of primary affective disorder. Second, research into the syndromal nature, biology, and treatment of PMS is still in its infancy due to a variety of methodological difficulties. Third, the rate of depression among women during the involutional period or following hysterectomy for benign pathology is not higher than it is at other times.