Psychiatric symptoms among patients with acute abdominal pain.

Background: Abdominal pain is a common cause of visits to emergency facilities. It is related to psychiatric disorders in primary care, but it is unclear if this also holds in emergency departments.Objective: Is to explore potential differences between diagnostic groups in patients with acute abdominal pain in an emergency ward regarding concurrent somatic-and psychiatric symptoms, 'Length of stay' (LOS) and perceived health.Method: The patients (N = 137) were divided into three groups; organic dyspepsia, specific abdominal diagnoses, and non-specific abdominal pain. The Prime-MD results for extra gastrointestinal symptoms (outside the gastrointestinal tract), psychiatric symptoms, frequency of symptoms, self-reported health, and LOS within the month before admittance were compared between the diagnostic groups.Results: There was a significant positive correlation between the number of physical extra gastrointestinal and psychiatric symptoms (p < .001), especially regarding anxiety (p < .001) and depression (p = .002). Patients with organic dyspepsia reported significantly more total (p = .016), extragastrointestinal (p = .026) (chest pain; p = .017, dizziness; p = .004, palpitations; p = .005, insomnia; p = .005 and worries; p = .001), and summarized anxiety and depression symptoms (p = .001-0.002) besides poorer general health (p < .001) compared to other abdominal conditions. Also, organic dyspepsia patients needed longer hospital stay than the non-specific abdominal group (p = .002) but similar to the specific abdominal disorders group.Conclusion: Organic dyspepsia is accompanied by more co-occurring physical, anxiety and depression symptoms as well as poorer perceived health than other abdominal pain conditions and comparably increased LOS. This suggests that psychiatric consultations might be beneficial for diagnosing and treating psychiatric comorbidity in emergency care.

The Adjustment Disorder Diagnosis, Its Importance to Liaison Psychiatry, and its Psychobiology.

Adjustment Disorder (AD) is one of the most common psychiatric diagnoses employed. In fact, it is the most frequent diagnosis utilized for psychiatric disorders in the military and in children, and is often utilized in the consultation-liaison medical setting. However, it is acknowledged that the diagnosis is not reliable, it cannot be validated, and it has an important degree of subjective consideration in its use. Commonly used screening tools like the Hamilton and Beck Depression Scales do not give an assessment of AD. Furthermore, its use is accompanied with descriptors of depression, anxiety, mixed affects, etc., so that it crosses over several areas of psychiatric dysfunction. It does allow the placement of a patient within a psychiatric diagnosis when they do not reach criteria for a major psychiatric nomenclature. To date, biological studies have not been reported. It is not known if AD with depression is closer to the biological characteristics of depression, or AD with anxiety would have similar characteristics to that seen with major anxiety. It is also not known if AD has a biological signature that would make them an entity with common features, or if they may be more closely allied biologically with the descriptor that accompanies them. Nevertheless, AD is an important category in any psychiatric lexicon and warrants further study and biological understanding.

Temperament and character in patients with acute abdominal pain.

BACKGROUND: Several conditions presenting with abdominal pain are associated with specific personality factors although it is unclear if this is true also in emergency clinic settings. OBJECTIVE: To study personality factors among patients with acute abdominal pain in an emergency ward. METHODS: Consecutive patients (N = 165) with abdominal symptoms at an emergency clinic were administrated the Temperament and Character Inventory (TCI). Three main groups were identified; specific abdominal diagnoses, (N = 77), non-specific abdominal pain, (N = 67) and organic dyspepsia (N = 21). TCI results were compared between clinical groups and a control group (N = 122). RESULTS: As compared to individuals with specific abdominal diagnoses and controls, those with organic dyspepsia were significantly more anxious (harm avoidance), (p = 0.003), and had lower ability to cooperate (cooperativeness) (p = 0.048 and p = 0.004 respectively). They were also significantly more unpretentious (self-transcendence) compared to individuals with specific abdominal diagnoses (p = 0.048), non-specific abdominal pain (p = 0.012) and controls (p = 0.004) and evidenced less mature character (sum of self-directedness and cooperativeness) compared to those with specific abdominal diagnoses and controls (p = 0.003). CONCLUSION: Individuals seeking care at an emergency clinic with organic dyspepsia showed a distinguishable pattern of personality features that distinguished them from the other comparison groups. Therefore an evaluation of personality factors may add a new dimension to the diagnostic investigation in the emergency care of abdominal pain and contribute to the optimization of the treatment of organic dyspepsia.

The psychobiology of stress, depression, adjustment disorders and resilience.

OBJECTIVES: This paper focuses on the psychobiology of stress, depression, adjustment disorders (ADs), and resilience. Since the ADs fall under the rubric in DSM-5 of Trauma and Stressor-Related Disorders, essentials of the psychobiology of stress-response syndromes will be reviewed. METHODS: A narrative review of the psychobiology of stress-response syndromes is undertaken, and the implications for our understanding of ADs are discussed. RESULTS: Advances in our understanding of the psychobiology of stress-response syndromes provide an important foundation for understanding ADs, and for conceptualizing their diagnosis, as well as issues of resilience. CONCLUSIONS: Future investigations of the psychobiology of trauma- and stressor-related disorders may shed additional light on ADs, and ultimately improve their treatment.

Ideology and Palliative Care: Moral Hazards at the Bedside.

Palliative care has had a long-standing commitment to teaching medical students and other medical professionals about pain management, communication, supporting patients in their decisions, and providing compassionate end-of-life care. Palliative care programs also have a critical role in helping patients understand medical conditions, and in supporting them in dealing with pain, fear of dying, and the experiences of the terminal phase of their lives. We applaud their efforts to provide that critical training and fully support their continued important work in meeting the needs of patients and families. Although we appreciate the contributions of palliative care services, we have noted a problem involving some palliative care professionals' attitudes, methods of decisionmaking, and use of language. In this article we explain these problems by discussing two cases that we encountered.

Resolution of amnestic effects of an extended course of electroconvulsive therapy.

We report the case of a 79-year-old man who had an episode of severe major depression treated with an extended course of electroconvulsive therapy (ECT) and multiple medication trials. Electroconvulsive therapy was only modestly beneficial, and he had significant cognitive effects. Neuropsychological testing at 2 different time points during the episode documented the cognitive deficits, as well as the time course of their resolution. He ultimately made a full recovery from his depressive episode with substantial improvement of ECT-related cognitive deficits. This case adds to the neuropsychological literature documenting the transient nature of ECT-induced cognitive effects.

Integrating primary care services into psychiatric care settings: a review of the literature.

OBJECTIVE: This review assesses the outcomes of integrating primary care medical services into psychiatric care settings. DATA SOURCES: PubMed, the Cochrane database, and PsycINFO were searched using the key words integrated care, family medicine, primary care, and internal medicine in combination with psychiatry or psychiatric clinic and ward to identify reports published between 1980 and December 2009 in English. STUDY SELECTION: Four studies evaluating medical care services on a psychiatry ward or in a psychiatry clinic were found. Trials involving psychiatric services in primary care clinics (the medical-psychiatric model) were excluded. DATA EXTRACTION: Data describing setting, patient population, intervention, measured outcomes, and discussion points were collected. DATA SYNTHESIS: It was learned that several models of integrated care exist, and patients in these integrated groups received more preventive health measures and showed improved scores on the Medical Outcomes Study 36-item Short-Form Health Survey and Behavior and Symptom Identification Scale and reduced rates of specialist referral. CONCLUSIONS: These data indicate that placing primary care physicians in psychiatric care settings improves health maintenance, care coordination, and satisfaction with nonpsychiatric medical care. Future studies should further address costs, the training of primary care physicians to deliver care in these settings, and whether this integrated model is more effective in specific populations such as those with schizophrenia.

The adjustment disorders: the conundrums of the diagnoses.

This article discusses the conundrums and the dilemmas of the conceptual framework of the diagnoses of the adjustment disorders (ADs). The psychiatric diagnoses that arise between normal behavior and the major psychiatric morbidities constitute the problematic subthreshold disorders. These subthreshold entities are also juxtaposed between problem-level diagnoses and more clearly defined major disorders. They present important taxonomic and diagnostic dilemmas in that they are often poorly defined, overlap with other diagnostic groupings, and have indefinite symptomatology. ADs were designed as a "wild card" to allow the coding of a psychiatric "diagnosis" for work done by psychiatrists and other mental health care specialists when the patient's symptoms do not reach the criterion of a major mental disorder. It is therefore not surprising that issues of reliability and validity prevail. The issues of diagnostic rigor and clinical utility seem at odds for the AD. Clinicians need a wild card, and field studies need to use reliable and valid concepts of AD and assessments instruments to determine more exact specification of the parameters of the diagnosis. Finally, appropriate and timely treatment is essential for patients with AD so that their symptoms do not worsen; their important relationships are not further impaired; or their capacity to work, study, or be active in their essential interpersonal pursuits is not compromised.

Adaptation of a Psychosomatic Medicine Computer Record System for Multi-Language Support: Making Psychiatric Computer Software Regionally Functional in Spanish- Speaking Countries* / La historia clínica sistematizada en medicina psicosomática

Electronic medical record (EMR) systems are becoming a standard for patient care, but are difficult to customize for local, regional, or international use. Particularly in the case of psychosomatic medicine, where diverse sociological, economical, cultural, and political influences may contribute to a patient’s disease state, EMRs have difficulty in being economically implemented. Careful, flexible computer program design, special editing systems to customize graphic user interfaces, and identifying localregional physician experts to assist in translation are keys to making a working application. We discuss the Micro-Cares™ CISCL Clinical Information System and the programming and customization decisions which have gone into adapting it for multi-language support. Discussed are the EMR design, adaptation for multiple hardware platforms (desktop, laptop and tablet computers, and on hand-held PDA systems), multi-tiered data storage, and customizable language manager, and questionnaire designer. Concepts of flexibly “scaling” CISCL to support the single user, or multiple user, or extensive department/ division personnel are discussed. Experience with regional testing and use are described, including modifications to the CISCL program that have been extensively user-guided. Finally, we examine standards of approach to multi-language support that have arisen from adapting CISCL to non-Romance-based languages, e.g., Mandarin. Our current experiences are summarized with description of on-going research efforts.

Los sistemas de registro médico electrónico (RME) se están convirtiendo en el estándar en cuanto al cuidado clínico del paciente se refiere, pero son difíciles de diseñar a medida para uso local, regional o internacional. Ésto es particularmente cierto en el caso de la medicina psicosomática, en la que diversas influencias de tipo sociológico, económico, cultural y político influyen en el estado del paciente, haciendo que los RME sean difíciles de implementar de manera económica. Un programa de computador diseñado de modo cuidadoso y flexible con sistemas de edición para personalizar gráficas, e identificar médicos expertos en el medio local-regional para que asistan en la traducción son las claves para hacer que una aplicación funcione. Presentamos el Micro-Cares™ CISCL Sistema de Información Clínica y discutimos la programación y las decisiones tomadas para adaptar el sistema a un soporte multilingüístico. Se discuten el diseño del RME, su adaptación para múltiples plataformas de hardware (computadores de escritorio, portátiles y tablet y sistemas PDA Palm™), sistemas de almacenamiento multinivel, administrador de idioma personalizado y diseñador de cuestionarios. También se discuten los conceptos de “escalonar” el CISCL de manera flexible para soportar un usuario único o múltiples usuarios, o personal numeroso de un departamento o división. Se presenta una descripción de las pruebas y uso a nivel regional, incluyendo modificaciones en el programa del CISCL que han sido guiados por los usuarios. Para finalizar, examinamos estándares de aproximación en soporte multilingüístico que han surgido al adaptar el CISCL a otros idiomas no basados en las lenguas romance, por ejemplo, el mandarín. Nuestras experiencias actuales se resumen con una descripción de nuestras investigaciones en curso.

Psychiatric diagnostic dilemmas in the medical setting.

OBJECTIVE: To review the problems posed for doctors by the failure of existing taxonomies to provide a satisfactory method for deriving diagnoses in cases of physical/psychiatric comorbidity, and of relating diagnoses on multiple axes. METHOD: Review of existing taxonomies and key criticisms. The author was guided in selection by his experience as a member of the working parties involved in the creation of the American Psychiatric Association's DSM-IV. RESULTS: The attempts of the two major taxonomies, the ICD-10 and the American Psychiatric Association's DSM-IV, to address the problem by use of glossaries and multiple axes are described, and found wanting. Novel approaches, including McHugh and Slavey's perspectives of disease, dimensions, behaviour and life story, are described and evaluated. The problem of developing valid and reliable measures of physical/psychiatric comorbidity is addressed, including a discussion of genetic factors, neurobiological variables, target markers and other pathophysiological indicators. Finally, the concept of depression as a systemic illness involving brain, mind and body is raised and the implications of this discussed. CONCLUSIONS: Taxonomies require major revision in order to provide a useful basis for communication and research about one of the most frequent presentations in the community, physical/psychiatric comorbidity.

Development of a Taiwanese computerized database for psychiatric consultation in a general hospital.

OBJECTIVE: The aim of this study was to evaluate the applicability of a modified questionnaire in psychiatric consultation and a new computerized software at one general hospital in Taiwan. METHOD: The Micro-Cares Clinical Information System for Consultation/Liaison Psychiatry (CISCL), an English language-based patient management application, has multiple clinical variables that were translated into Mandarin Chinese. The Mandarin Chinese version of the Micro-Cares Questionnaire (MCMQ) was further modified after extensive testing and clinical use by two staff psychiatrists and eight senior resident doctors. In addition, the structure of the Mandarin Chinese version of the Micro-Cares CISCL Program (MCMP) was created for direct information entry through a specialized Microsoft Access-based support module. RESULTS: The MCMQ has been adapted to regular medical practice. Up to 66% of the consultation cases (618/913 patients) were recorded in 2003. Among those registered, 519 (84%) received psychiatric diagnoses. Eight of the 10 participants evaluated agreed that the MCMQ was clinically applicable. CONCLUSION: MCMQ and MCMP have been routinely applied in the clinical, administrative, research and educational services of our psychiatric consultation.

Psychotropic drug versus psychotropic drug-update.

Psychotropic drugs are not necessarily the drugs of psychiatry. Seventy percent of antidepressants, and 90% of anxiolytics are prescribed by nonpsychiatric physicians. Since psychotropic medications are so frequently employed by nonpsychiatric physicians, e.g., neurologists, primary care physicians, internists, and because large numbers of their patients are concurrently on medical drugs for somatic reasons, the interactions of psychotropic versus medical drugs and psychotropic versus psychotropic drugs as listed below must be understood before primary care physicians or psychiatrists prescribe psychotropic medications, especially to the medically ill. Seventy commonly prescribed psychotropic drugs were examined for their interactions with other psychotropic medications using six reference tools: 1) MEDLINE (PubMed) employing the first generic psychotropic drug name, the second generic psychotropic drug name, and the term "interaction;" 2) Hanston's Drug Interaction Analysis and Management Text (quarterly updated version); 3) Drug Interactions Facts (Facts and Comparisons) (July 2001 quarterly updated version); 4) Micromedex Drug-dex; 5) American Hospital Formulary Service Drug Information; and 6) Food and Drug Administration (MedWatch) (Dear Doctor Letters and new labeling) ( for (1999, 2000, and 2001). The authors recognized that all of the above sources do not necessarily cover the entire information database regarding drug-drug interactions. (Citations regarding children, reports in foreign languages or concerning food, animals, in vitro experiments, analgesics, and naturalistic-herbal or natural products-treatment interactions were excluded).

Congestive heart failure and depression in older adults: clinical course and health services use 6 months after hospitalization.

The course of depression and the economic consequences in the 6-month period after hospitalization for congestive heart failure were examined in a prospective observational cohort study involving 203 older adults (mean age=76.8 years, SD=7.8). At discharge, 73 of 203 subjects (36%) were depressed according to the screening criteria of the Geriatric Depression Scale, and 44 (22%) were depressed according to the Structured Clinical Interview for DSM-III-R-Non-Patient Edition. The proportions were 33% and 20% of 166 subjects, respectively, at 4 weeks and 26% and 17% of 113 subjects, respectively, at 24 weeks. Depressed patients used more medical resources after discharge than nondepressed patients. Additional research is required to determine whether the optimal time to identify and treat depressed older adults with congestive heart failure is during a hospital stay or after discharge.

Consultation-Liaison Psychiatry Literature Database (2003 update). Part I: Consultation - Liaison Literature Database: 2003 update and national lists.

Every day there are 10,000 scientific articles published. Since the Consultation-Liaison ("C-L") psychiatrist may be asked to consult on a patient with any medical illness, e.g., severe acute respiratory syndrome (SARS), malaria, cancer, stroke, amytrophic, lateral sclerosis, and a patient who may be on any medical drug, methods need to be developed to review the recent literature and have an awareness of key and essential current findings. At the same time, teachers need to develop a current listing of seminal papers for trainees and practitioners of this newest cross-over subspecialty of psychiatry-now called Psychosomatic Medicine. Experts selected because of their writings and acknowledged contributions to a specific clinical area or problem hope examined thousands of citations to choose those articles, chapters, books, or letters that they regard as most important to Psychosomatic Medicine. In addition, psychiatric specialists in six countries have provided their national Psychosomatic Medicine (Consultation-Liaison) lists as examples of what they regard as the most important teaching materials journals: Australia, Brazil, Greece, Mexico, Portugal, and Taiwan. It is our belief that a cogent, international, systematic review will provide the greatest success in creating a "regionally appropriate" teaching and consultation literature database with world-wide applicability. We review our current progress on this literature database and software, the technical system and data organization involved, the approach used to populate the literature system, and ongoing development plans to bring this system to the physician via mobile technologies.

Comparison of three methods for identifying medical drug-psychotropic drug interactions.

Three methods for examining drug-drug interactions were compared to understand advantages and disadvantages of each: ePocrates; Interact; The Mount Sinai multiple source for the evaluation of drug-drug interactions (MS). ePocrates is a commonly employed software system utilized in a hand held computer, the PalmPilot. Interact is on a CD-ROM, and promoted by the American Psychiatric Association Press. The MS system was developed by the authors and utilizes six separate references sources to ascertain the presence and significance of drug-drug interactions. Commonly prescribed neurology and psychotropic medication interactions were compared using the three systems. ePocrates did not list the significance level of the interaction, e.g., (major, moderate, minor), often did not include a mechanism of action, and several commonly employed medications were not included. It did permit examining several drugs at the same time, and was easily carried on the person of the physician. Interact often contained old references, several drugs were not included, was not adapted to a hand held computer format, and had no update since 1999. The MS system listed level of significance, provided mechanism of action, and advice to the practitioner including recommendations. It is not portable, requiring a laptop or desk top computer or hard copy, and only searches one drug at a time. It is hoped that the advantages of each of these three systems may be incorporated into systems of the future.