Cannabinoid hyperemesis: cyclical hyperemesis in association with chronic cannabis abuse.

BACKGROUND AND AIMS: To explore the association between chronic cannabis abuse and a cyclical vomiting illness that presented in a series of cases in South Australia. METHODS: Nineteen patients were identified with chronic cannabis abuse and a cyclical vomiting illness. For legal and ethical reasons, all patients were counselled to cease all cannabis abuse. Follow up was provided with serial urine drug screen analysis and regular clinical consultation to chart the clinical course. Of the 19 patients, five refused consent and were lost to follow up and five were excluded on the basis of confounders. The remaining nine cases are presented here and compared with a published case of psychogenic vomiting. RESULTS: In all cases, including the published case, chronic cannabis abuse predated the onset of the cyclical vomiting illness. Cessation of cannabis abuse led to cessation of the cyclical vomiting illness in seven cases. Three cases, including the published case, did not abstain and continued to have recurrent episodes of vomiting. Three cases rechallenged themselves after a period of abstinence and suffered a return to illness. Two of these cases abstained again, and became and remain well. The third case did not and remains ill. A novel finding was that nine of the 10 patients, including the previously published case, displayed an abnormal washing behaviour during episodes of active illness. CONCLUSIONS: We conclude that chronic cannabis abuse was the cause of the cyclical vomiting illness in all cases, including the previously described case of psychogenic vomiting.

Citizen centered health and lifestyle management via interactive TV: The PANACEIA-ITV health system.

In the context of an IST European project with acronym PANACEIA-ITV, a home care service provisioning system is described, based on interactive TV technology. The purpose of PANACEIA-ITV is to facilitate essential lifestyle changes and to promote compliance with scientifically sound self-care recommendations, through the application of interactive digital television for family health maintenance. The means to achieve these goals are based on technological, health services and business models. PANACEIA-ITV is looking for communication of monitoring micro-devices with I-TV set-top-boxes using infrared technology, and embodiment of analogous H/W and S/W in the I-TV set-top-boxes. Intelligent agents are used to regulate data flow, user queries as well as service provisions from and to the household through the satellite digital platform, the portal and the back-end decision support mechanisms, using predominantly the Active Service Provision (ASP) model. Moreover, interactive digital TV services are developed for the delivery of health care in the home care environment.

A video review of the diagnosis of psychogenic gait: appendix and commentary.

The gait and other clinical features of 22 patients presenting to our hospital over the last 10 years are shown on video. In 12 patients, a diagnosis of psychogenic gait was made; in the remainder, the gait abnormality was the result of a neurologic disease. Psychogenic gaits are compared and contrasted with "organic" gaits. In one patient, the psychogenic gait occurred in the setting of a neurologic disease. The "traditional" approach to psychogenic gait, attempting to exclude underlying neurologic and psychiatric disease and seeking evidence for primary and secondary gain, was found to be of limited value. More useful were the features of the gait itself, in particular, exaggerated effort, extreme slowness, variability throughout the day, unusual or uneconomic postures, collapses, convulsive tremors, and distractibility; certain aspects of the history were also helpful. A list of comments is provided. The diagnosis of psychogenic gait, particularly in the elderly, remains fraught with hazard, and a balance has to be sought between subjecting an anxious patient to needless investigations and yet not losing sight of the fact that the patient may be elaborating on symptoms of genuine disease. The bizarre gait of some neurologic disorders, particularly dystonia and chorea, may be a pitfall for the unwary.

Antidepressant treatment of depression in HIV-seropositive women.

BACKGROUND: This study aimed to assess the effectiveness of fluoxetine and sertraline in treating depressed women who are seropositive for the human immunodeficiency virus (HIV) and to document barriers to study participation. METHOD: Ambulatory HIV-seropositive women with DSM-IV depressive disorders were enrolled in an 8-week, open trial of fluoxetine (N = 21) or sertraline (N = 9) initiated at standard dosages. Outcome measures included the Clinical Global Impressions-Improvement scale (CGI), Hamilton Rating Scale for Depression (HAM-D), Beck Depression Inventory (BDI), physical function ratings, and CD4 count. RESULTS: Thirty-six women were screened for the study and 30 were enrolled. Mean age was 35.5 years and HIV risk was primarily intravenous drug use (N = 16; 53%) or heterosexual contact (N = 12; 40%). Sixteen (53%) were Hispanic, 11 (37%) were African American, and 3 (10%) were white. Mean +/- SD CD4 count was 463+/-312 cells/microL, and 30% had acquired immunodeficiency syndrome (AIDS). Eighteen women (60%) completed the trial (14 fluoxetine: dose range, 10-40 mg/day; 4 sertraline: dose range, 25-100 mg/day). Of completers, 14 (78%) were clinical responders by CGI and reduction in HAM-D > 50%. Statistically significant reductions were seen in HAM-D and BDI scores, but not in measures of physical function or CD4 count. The most frequent adverse effects were anxiety, overstimulation, and insomnia. Reasons for nonparticipation or dropout included refusal to accept antidepressants on account of negative bias, preferring psychotherapy alone, adverse effects, and relapse to illicit drugs. CONCLUSION: While HIV-seropositive women may benefit from antidepressant treatment, multiple barriers to successful treatment exist. Aggressive outreach, education, and attention to the complex psychosocial needs of HIV-seropositive women are essential components of depression treatment in this population.

Suicide attempts by firearms and by leaping from heights: a comparative study of survivors.

OBJECTIVE: The purpose of this study was to compare the clinical and demographic profiles of patients who deliberately harmed themselves, either by jumping from a great height or by using firearms, and survived. METHOD: The study consisted of an 18-year retrospective case history analysis of survivors of jumping and shooting identified from the database of consultation-liaison psychiatry referrals at a hospital in Sydney, Australia. Clinical and demographic information was collated and analyzed. RESULTS: Fifty-one patients who had shot themselves and 31 patients who had jumped, all of whom had survived, were assessed by the consultation-liaison psychiatry team. There were clear differences between the two groups. Those who jumped were more likely to be single, unemployed, and psychotic. Those who used firearms were more likely to be male, abuse alcohol, have a forensic history, and have an antisocial or borderline personality disorder. CONCLUSIONS: In this study, the subjects who attempted suicide by shooting themselves and those who did so by jumping had different profiles of mental state, personality function, and psychiatric diagnosis. The importance of mental state and specific psychiatric diagnosis as determinants of the method used has been neglected in studies of suicide. These factors should be considered along with others such as accessibility and acceptability of means, since these differences may be important when suicide prevention is considered. It is also important for psychiatrists providing consultation-liaison services to be aware of these differences in order to ensure optimal treatment of survivors.

The suicide of Thomas Wentworth Wills.

Thomas Wentworth Wills was the most important Australian sportsman of his time. He captained the Victorian colony at cricket and was the first hero of Australian Rules football. Although his picture now adorns the conservative Melbourne Cricket Club, he died in 1880, an isolated, destitute alcoholic, after stabbing himself in the heart. Wills embodied a tradition, as prevalent today as it was over 100 years ago, that weds sport with alcohol in Australian culture.

Delirium in hospital: does it increase length of stay?

OBJECTIVE: To determine the effect of delirium, as a comorbid diagnosis in hospitalised patients, on patient length of stay (LOS). METHOD: Prospective study comparing LOS of delirious patients with controls matched by age, gender, principal diagnosis and date of admission. Medical and surgical inpatients of Westmead Hospital with delirium were identified from a Consultation Liaison (CL) psychiatry database and were matched with controls from the hospital medical records. RESULTS: Delirious patient LOS was found to be significantly longer (2.2-fold; 95% confidence interval 1.5-3.3) than matched controls. CONCLUSIONS: Delirium, as a comorbid diagnosis in general hospital patients, is associated with an increased use of resources. Its early diagnosis may limit this and morbidity.

Suicide in the 18 years after deliberate self-harm a prospective study.

BACKGROUND: Clinical and demographic information on patients seen as a result of deliberate self-harm (DSH) was collected in an attempt to identify factors in the index episode of DSH predictive of subsequent suicide. METHOD: Specific data were prospectively collected on all DSH patients who lived in Blacktown Municipality, Sydney, Australia, and seen from October 1975 to September 1976. Follow-up at 18 years was by evaluation of coroners records and identification of probable suicide. RESULTS: Two hundred and twenty-three patients harmed themselves on one or more occasions. Follow-up at 18 years showed that 15 of the 223 (6.7%) had completed suicide. The proportion at five and eight years was 4.0% and at 10 years was 4.5%. Identified predictors of suicide were: narcotic overdose; more than one episode of DSH in the year of the study; planned episode; and mental illness. Teenage narcotic-abusing males were at greatest risk and in females a planned episode was the most powerful predictor. CONCLUSIONS: Suicides continued to occur over 18 years. One of the striking differences between this and other studies is the finding of teenage male DSH, associated with narcotic abuse, as a strong predictor of subsequent suicide. These findings are particularly relevant to the issue of young male suicide, which increased from the 1970s onwards in Australia and elsewhere.

Jumping the gun: firearms and the mental health of Australians.

OBJECTIVES: The aims of this study were to (i) survey mental health-related correlates of firearms ownership and availability in Australia, and (ii) assess possible causal relationships between civilian gun deaths, gun availability and mental disorders. METHOD: Available data regarding firearms ownership, injuries and deaths were reviewed as well as studies of (i) gun ownership, suicide and homicide, and (ii) gun control laws and suicide. RESULTS: Findings indicated that 85% of firearm deaths are triggered by distress, as opposed to crime. Most firearm homicides are intrafamilial or involve familiar persons. Firearm suicide rates, although tapering off in recent years, continue to rise among certain groups. It was also found that: (1) Beyond reasonable doubt, a causal relationship exists between gun ownership and firearm suicides and homicides. The role of method substitution is controversial, but is probably less important among the young. (2) Outside the United States, legislation may be useful in reducing firearm and possibly overall suicide rates. (3) If firearm owners are representative of the community, then 15-20% suffer from a psychiatric disorder at any time. While a modest increase in risk of firearms misuse exists for this group, especially those with a history of substance abuse or violence, concern also arises regarding those with mental disorders who access firearms because owners have not secured them. No uniform definition or way of verifying self-reports exists for gun licence applicants regarding these issues. CONCLUSIONS: Further regulation of firearm safety and availability is warranted. Public health measures include improved surveillance regarding firearm events, advocacy for appropriate firearm legislation, and better education and communication about firearms.

Psychogenic vomiting complicated by marijuana abuse and spontaneous pneumomediastinum.

OBJECTIVE: This case illustrates an unusual physical sequel of psychogenic vomiting. CLINICAL PICTURE: A 22-year-old man with a picture of psychogenic vomiting and marijuana use developed the complications of a pneumomediastinum and subcutaneous emphysema. TREATMENT: Therapy included gradual exposure to anxiety provoking stimuli, psychotropics to reduce vomiting and psychotherapeutic exploration of family relationships. OUTCOME: The patient's vomiting and physical state resolved without complication. Follow-up at 12 months revealed continued improvement with occasional less severe vomiting. CONCLUSIONS: Psychogenic vomiting as a manifestation of anxiety can result in serious physical and psychological sequelae. This patient's desperate attempts to control such vomiting complicated the picture. Successful short term intervention included the use of several treatment modalities.

Becoming none but tradesmen: lies, deception and psychotic patients.

Is there ever any reason for a doctor to lie to a patient? In this paper, we critically review the literature on lying to patients and challenge the common notion that while lying is unacceptable, a related entity--'benevolent deception' is defensible. Further, we outline a rare circumstance when treating psychotic patients where lying to the patient is justified. This circumstance is illustrated by a clinical vignette.

Survivors of self-inflicted firearm injury. A liaison psychiatry perspective.

OBJECTIVE: To examine the clinical profile and, in particular, the psychopathology of 33 survivors of self-inflicted firearm injury. DESIGN: An eight-year retrospective case history analysis. Information was obtained from databases in the Psychiatry, Trauma and Medical Records departments of Westmead Hospital. RESULTS: In the sample most survivors of self-shooting were young men who did not suffer from major depression or psychosis. Most shootings occurred in the context of interpersonal disputes with sexual partners or family members. CONCLUSIONS: Most patients who survive self-inflicted firearm injuries have shot themselves impulsively in a crisis, are not psychotic, and have ready access to firearms. Psychiatric care is usually given in the trauma ward. Close cooperation is required between psychiatric and surgical teams in management. Recommendations to assist in the more accurate assessment of patients with self-inflicted firearm injury include: careful scrutiny of alleged accidental shootings; the inclusion of police information in the assessment; routine drug screening and determination of blood alcohol level; repeated interviews and corroboration of patient claims by family and friends; and psychiatric review of all patients with self-inflicted injury.

Harakiri: a clinical study of deliberate self-stabbing.

BACKGROUND: Stabbing is an uncommon method of self-harm that has not been previously described in the psychiatric literature. The aim of this study was to describe the clinical features and management of patients presenting with self-inflicted stab injuries. METHOD: Case notes of all patients presenting with deliberate self-inflicted injuries during a 2-year period to a teaching general hospital were screened to identify the sample of interest. Clinical data were then collected by means of a detailed case-note study. RESULTS: Ten patients who deliberately stabbed themselves were identified. The patients fell into two distinct clinical groups: the first consisted mostly of young men with antisocial personalities who were intoxicated at the time of the self-stabbing and who reported ambivalent suicidal intent; the second consisted of psychotic patients, most of whom were actively ill at the time of the self-stabbing, and who reported clear suicidal intent. Patients in the first group were noncompliant with treatment and difficult to engage; those in the second group needed psychiatric hospitalization and often responded to antipsychotic medication. CONCLUSION: Persons who stab themselves tend to fall into two clinical groups that have different diagnoses and management. Distinctions between violent suicidal behavior and self-mutilation are blurred because suicidal intent can be difficult to assess.