Mortality and medical comorbidity among psychiatric patients: a review.

OBJECTIVES: To fuel advocacy for improved health care for mentally ill persons, the authors reviewed the literature that describes excess mortality and underrecognition and undertreatment of comorbid medical conditions in this population. Barriers to optimal primary medical care for psychiatric patients are discussed. METHODS: A MEDLINE search focusing on mortality and medical problems in psychiatric patients yielded 66 papers in English published between 1934 and 1996. These studies and a German paper from 1912 are included in the review. RESULTS AND CONCLUSIONS: Standardized mortality ratios for psychiatric patients, derived from comparisons with the general population and matched control groups, have repeatedly demonstrated excess mortality from both natural and unnatural causes among psychiatric patients. Several large studies that have attempted to clarify the issues underlying increased death rates are discussed. Although no single diagnostic group emerges as being at particularly high risk, substance abuse disorders alone or in combination with other psychiatric disorders have been repeatedly found to lead to increased mortality rates. Other studies have also repeatedly demonstrated that psychiatric patients suffer a high rate of comorbid medical illnesses, which are largely undiagnosed and untreated and which may cause or exacerbate psychiatric symptoms. Atypical presentations are common, and changes in vision are the symptoms most predictive of medical illness. Elderly patients and those with diagnoses of organic brain syndromes are at highest risk for comorbid medical illness. Parity in the medical and mental health treatment of psychiatric patients requires both political advocacy and development of primary care programs capable of efficiently meeting their needs.

Postpartum psychosis induced by bromocriptine.

Two multigravida patients with no prior psychiatric history were seen with postpartum psychosis, having received bromocriptine for inhibition of lactation. Bromocriptine given in high doses has been associated with psychosis in patients receiving the drug for Parkinson's disease. These cases demonstrate that bromocriptine may cause psychosis even when given in low doses.

Polyuria among patients with psychosis.

Using the criterion of early morning urinary specific gravity (SPGR) of 1.008 or less to define the presence of polyuria, we identified 26 of 72 male (36 percent) and 14 of 31 female (45 percent) institutionalized chronically psychotic patients as polyuric during a comprehensive survey of one of the chronic care units at a State mental hospital. Factors including diagnosis, sex, age, weight, and serum sodium did not distinguish the polyuric from the nonpolyuric patients. For men, administration of lithium was associated with polyuria. Urinary creatinine concentration (UCR) correlated well with SPGR, and UCR may provide an alternate index to separate polyuric from nonpolyuric patients. The clinical implications of our findings are discussed.

Tricyclic antidepressant use in a patient with bundle branch blocks and ventricular ectopy.

Amoxapine, a dibenzoxapine tricyclic antidepressant, was used successfully to treat a depressed elderly woman with left anterior hemiblock, right bundle branch block, and ventricular ectopy. This case highlights the importance of serial electrocardiographic monitoring in depressed patients with cardiac abnormalities treated with tricyclic antidepressants. The apparent reduction of ectopy in this case indicates a possible quinidine-like action of amoxapine.

Impotence: are the newer diagnostic methods a necessity?

Until recently our evaluation of impotent men included a psychiatric evaluation, and history and physical examination by a urologist to determine whether the impotence was organic or psychogenic. After the introduction of specific laboratory methods, such as nocturnal penile tumescence monitoring and penile blood pressure studies, clinicians relied heavily on these tools. We evaluated 33 impotent patients and compared the results of the laboratory methods to the initial diagnoses of the psychiatrist and the urologist to determine if the new methods would confirm our initial impressions or uncover different diagnoses. Thirteen patients were considered to have psychogenic impotence by the clinicians and only 1 patient in this group had evidence of organicity when the laboratory tests were used. Twelve patients were considered to have organic impotence by the clinicians and this was confirmed in 75 per cent of the cases by laboratory testing. Thus, clinical evaluation predicted the outcome of laboratory methods in 92 per cent of the psychogenic group and 75 per cent of the organic group. In addition, postage stamps were used during nocturnal penile tumescence monitoring and in predicting the outcome of nocturnal tumescence monitoring the stamp test had a sensitivity and a specificity of 91 per cent. Many patients presenting with erectile impotence can be evaluated adequately by a psychiatrist and a urologist without the support of expensive laboratory tests. The postage stamp test is useful when nocturnal penile tumescence monitors are not available. Finally, the Minnesota Multiphasic Personality Inventory is of limited value as a screening device.

A conjoint psychiatry-internal medicine program: development of a teaching and clinical model.

At a time when psychiatry's repertoire of successful treatment strategies is burgeoning and the public is seeking primary medical care with greater emphasis on humanistic issues, psychiatry has been paradoxically losing status and trainees, partly because it has failed to make its expertise integratable by nonpsychiatric physicians. In response to the educational and patient care deficiencies that result, two universities developed a teaching and clinical program that leads to partial integration of their departments of psychiatry and internal medicine. This collaborative approach includes a conjoint internal medicine-behavioral medicine inpatient unit and a residency program leading to Board eligibility in both specialties.