Quo vadis, psychiatry? Problems and potential for the future of medical student education in psychiatry.

Psychiatric education occupies a relatively low status level in most academic departments of psychiatry. This problem may be in part because career teachers rarely generate sustained external grant support. Their salaries may be regarded as perpetual drains on the budgets of department chairs. The author explores a possible relationship between the decline in the emphasis on psychiatric education and the decline in the number of medical students entering psychiatric residency programs. Recommendations for improvement in the support of psychiatric education are made that focus on greater accountability of how tuition fees are distributed to support the salaries of faculty educators. The unique role that consultation-liaison (C-L) psychiatry occupies in psychiatric education, the effects of managed care on C-L psychiatry, and the special problems that C-L psychiatry currently faces with its strong emphasis on non-reimbursable educational activities are discussed. Revitalization of the importance of education in undergraduate medical education is vital for the future of psychiatry.

Qualitative outcome assessment of a medical ethics program for clinical clerkships: a pilot study.

This study assessed the usefulness of an open-ended case analysis test instrument for evaluating the effects of a 1-year ethics course on medical students' decision-making skills. Through case-oriented seminars in gynecology, internal medicine, obstetrics, pediatrics, psychiatry, and surgery, third-year medical students were taught a structured analytic framework for analyzing clinical ethical problems stressing the interactive relationships among medical indications, patient preferences, quality of life, and contextual (social, legal, economic) matters. At precourse, the students were given a test case and asked to provide a line of reasoning for their clinical decisions. At postcourse, the students were given the same case. Content analysis of pre- and postcourse responses of a random student sample revealed increases in student awareness in the following areas: 1) consideration of informed consent, 2) professional liability, 3) physician-assisted suicide, and 4) resource utilization. With some modifications, open-ended case analysis holds promise for evaluating medical ethics courses. The authors make recommendations for future research in evaluating the true impact of clinical ethics courses in medical education.

Neuropsychiatric toxicity associated with cytokine therapies.

The cytokines interleukin-2 and interferon-alpha are potent biological agents used to treat malignancy, infectious diseases, and neurodegenerative disorders. While these medications show substantial therapeutic promise, the neuropsychiatric toxicity associated with these agents is often treatment-limiting. The pathophysiology of this toxicity is not well delineated, and adverse effects to the central nervous system are often misdiagnosed by clinicians. This report reviews the preclinical and clinical literature describing the morbidity associated with these agents and suggests appropriate clinical management strategies and future directions for research.

Changing attitudes about end-of-life decision making of medical students during third-year clinical clerkships.

To better define the learning objectives of ethics curricula and evaluate changes in medical students' attitudes about end-of-life decision making, enrolled students (N = 96) of a pilot medical ethics program were surveyed at the beginning and end of their third-year clinical clerkship about their experiences and attitudes about end-of-life decision making. At the end of their clinical clerkship year, the majority of students had participated in end-of-life decisions, prioritized patient autonomy and quality-of-life issues, were concerned about legal liability, were polarized over issues such as physician-assisted suicide, and gained confidence in their ethical decision-making ability. To train future physicians such that clinical practice is consistent with ethical guidelines and legislation on end-of-life care, medical ethics curricula should focus on symptom relief, clarification of legal issues, and resolution of conflicts between personal beliefs and public opinion about such issues as physician-assisted suicide. Appropriate role-modeling and mentoring by residents and attending physicians should also be emphasized.

Medical assessment of patients presenting with psychiatric symptoms in the emergency setting.

Psychiatrists in the emergency department (ED) are often asked to evaluate patients with disturbances of affect, behavior, and cognition. The first and most crucial step in the evaluation process is to eliminate possible medical causes for a patient presenting psychiatric symptoms. Failure to detect and diagnose underlying medical disorders may result in significant and unnecessary morbidity and mortality.

The Academy of Psychosomatic Medicine practice guidelines for psychiatric consultation in the general medical setting. The Academy of Psychosomatic Medicine.

This practice guideline seeks to provide guidance to psychiatrists who regularly evaluate and manage patients with medical illnesses. The guideline is intended to delineate the knowledge base, professional expertise, and integrated clinical approach necessary to effectively manage this complex and diverse patient population. This guideline was drafted by a work group consisting of psychiatrists with clinical and research expertise in the field, who undertook a comprehensive review of the literature. The guideline was reviewed by the executive council of the Academy of Psychosomatic Medicine and revised prior to final approval. Some of the topics discussed include qualifications of C-L consultants, patient assessment, psychiatric interventions (e.g., psychotherapy, pharmacotherapy), medicolegal issues, and child and adolescent consultations.

Recovery and relapse in geriatric depression after treatment with antidepressants and ECT in a medical-psychiatric population.

The objective of this naturalistic, longitudinal treatment outcome study was to determine relapse rates in geriatric depression following treatment with antidepressants and electroconvulsive therapy in a medical-psychiatric population. Thirty-nine elderly patients (average age 71 years) with unipolar major depression were treated with either antidepressants (AD) or, if resistant to AD treatment, ECT followed by maintenance antidepressants. Patients were monitored over 18 months, and relapse rates were closely determined using the Longitudinal Interval Follow-up Evaluation (LIFE) and the 21-item Hamilton Depression Rating Scale. Although 90% of patients recovered from their index episode of depression, relapse rates were approximately 29%. These results indicate that in spite of high chances of recovery from geriatric depression, intensive psychopharmacologic and psychotherapeutic strategies are needed to decrease relapse rates in geriatric depression.

Psychopharmacologic treatment of depression in the medically ill.

Appropriate selection of an antidepressant agent in medically ill patients requires a careful risk-benefit assessment matching the pharmacokinetic and pharmacodynamic properties of the drug being considered against the patient's physiological vulnerabilities, potential for drug interactions, and primary symptoms of the patient's depression. While in the past antidepressant drug selection was limited by the almost sole availability of the tricyclic antidepressants, newer drugs such as selective serotonin reuptake inhibitors, bupropion, and venlafaxine have vastly simplified treating depression in the medically ill. In refractory cases of depression in patients with medical illness, electroconvulsive therapy can be used with appropriate anesthetic management.

Lithium intolerance in a medical-psychiatric population.

This pilot study was designed to explore the tolerance and efficacy of lithium as an adjunctive prophylactic agent when added to maintenance antidepressant regimens following an episode of depression in an older medical-psychiatric population. In a randomized controlled trial, 27 depressed patients had either lithium carbonate or placebo added to their maintenance antidepressant (AD) regimen following an index episode of depression. Of 17 patients who received lithium carbonate, 76% (13/17) were unable to tolerate this agent for the duration of the study because of side effects (e.g., gastrointestinal disturbances or tremor). The four patients who tolerated lithium were monitored for relapse of depression over a 15-month follow-up period, and one relapsed (after a 49-week remission) whereas 60% (6/10) of the placebo patients relapsed. Cognitive functioning was stable in the lithium-treated patients who remained on therapy. The high rate of lithium intolerance in this study indicates that lithium dosing and serum levels must be conservatively managed in this clinical population.

Recurrence and relapse in geriatric depression: a review of risk factors and prophylactic treatment strategies.

An emerging body of epidemiologic data has substantiated that in younger and middle-aged populations, major depression may be characterized by early relapse, recurrence, and chronicity. Information regarding the prognosis of geriatric depression is less extensive. This article reviews the literature on the longitudinal outcome of major depression in older adults, with particular emphasis on the limited data on strategies for the pharmacologic and electroconvulsive prophylaxis of recurrent unipolar geriatric depression. Possible biological markers for relapse risk, derived from sleep electroencephalography, neuroendocrine tests, and neuroradiographic findings, are also discussed. Recommendations for the treatment and long-term follow-up of geriatric depression are presented.

Psychiatry in medical practice. Implications for the education of primary care physicians in the era of managed care: Part 2.

In Part 1 of this 2-part series, the epidemiology of psychiatric disorders in primary care settings was reviewed as well as evidence that indicates that these conditions often go underrecognized and undertreated by primary care physicians. Educational studies to improve the psychiatric skills of primary care physicians were also reviewed. In Part 2 of this series, a core curriculum for primary care physicians in the diagnosis and treatment of psychiatric disorders that emphasizes competency-based learning is presented. Recommendations for the development and implementation of these competency-based training modules are offered in the conclusion.

Effects of depressive disorders on coronary artery disease: a review.

Evidence suggests that major depression and ischemic heart disease commonly co-occur and that depressive symptoms have a negative impact on cardiovascular prognosis. A Medline search was conducted to obtain articles published between 1966 and 1996 that address the association between depressive disorders and coronary artery disease. We used systematic epidemiologic criteria to examine the strength of this association. There is convincing evidence that in patients with coronary artery disease, depressive disorders are common and are associated with increased rates of morbidity and mortality. Several biological mechanisms have been proposed to explain the association, including alterations in autonomic function leading to increased risk of ventricular arrhythmias. Despite the evidence that their comorbid presence is associated with increased morbidity and mortality, depressive disorders in patients with coronary artery disease are often underdiagnosed and inadequately treated. At the very least, randomized treatment trials are indicated.

Major depression in the primary care setting.

This article has provided a brief overview of the prevalence, differential diagnosis, and clinical manifestations of depression in the primary care setting. While the high prevalence of depression is well documented, another body of evidence is accruing that demonstrates that depression not only increases over utilization of medical resources, but may worsen the long-term prognosis of certain medical conditions such as MI. Evidence also suggests that the diagnostic and management skills of primary care physicians--who comprise the "front line" and may offer the only line of care for these patients--is in need of improvement. This series of articles focusing on the diagnosis and treatment of depression in primary care will hopefully contribute to that effort.

Psychiatry in medical practice. Implications for the education of primary care physicians in the era of managed care: Part 1.

In an effort to control the costs of mental health care, many medical care systems have emphasized the management of psychiatric illness by primary care physicians and curtailed specialty mental health referrals. While this trend mandates that primary care physicians have expertise in the diagnosis and treatment of psychiatric disorders, evidence indicates that not only are psychiatric disorders underrecognized in primary care settings, but also that treatment is often inadequate and accompanied by less than optimal outcomes. In Part 1 of this 2-part series, representative studies of the epidemiology of psychiatric disorders in primary care are reviewed in addition to data that has documented low rates of recognition and suboptimal management of psychiatric illness. In Part 2, to be published in the January-February 1997 issue of Psychosomatics, a core psychiatric curriculum for primary care physicians will be presented that emphasizes the use of competency-based training modules. Strategies for the development and implementation of these educational training modules will also be discussed.

New antidepressant drugs and the treatment of depression in the medically ill patient.

The advent of the SSRIs, venlafaxine, bupropion, and nefazodone, has greatly expanded pharmacologic treatment options for the depressed medically ill patient. Although the relatively benign side effects of these medications on cardiac conduction and blood pressure allow for more liberal use in the medically ill, these drugs nevertheless have different capacities for adverse drug interactions that must be considered. Nevertheless, such interactions can usually be avoided or managed by knowledgeable clinicians cognizant of the pharmacodynamic and pharmacokinetic principles outlined in this article.

Corticosteroid-induced delirium and dependency.

A case of a patient with chronic lung disease who developed an addiction pattern of corticosteroid dependency is described in which steroid-induced delirium also developed. The rare phenomenon of corticosteroid dependency is discussed as well as the phenomenology and possible mechanisms of steroid-induced delirium.

OBRA regulations and the use of psychotropic drugs in long-term care facilities: impact and implications for geropsychiatric care.

This article reviews governmental guidelines regulating the use of psychotropic drugs in long-term care facilities as established by the Omnibus Budget Reconciliation Act (OBRA) of 1987 and their impact on the use of psychotropic agents in these settings. A major component of these guidelines is to regulate the clinical indications for psychoactive drugs (neuroleptics, benzodiazepines, and sedative hypnotics) in residents of long-term care facilities. Responsibilities of the prescribing physician, facility medical director, and consulting pharmacist--as well as quality assurance procedures-in complying with OBRA regulations are examined. Evidence that OBRA regulations have reduced the use of psychotropic drugs and physical restraints in long-term nursing facilities is reviewed. Implications of the OBRA regulations for the training and clinical practice of psychiatrists and primary care clinicians are discussed as well as recommendations for increasing the availability of mental health services for this patient population via multidisciplinary geropsychiatric consultation-liaison teams.