A. Dale Gulledge

Depression, immunocompetence, and prostaglandins of the E series

Plasma prostaglandin E1 and E2, and quantitative and qualitative measures of immune function, were determined in depressed patients and healthy controls. Prostaglandin E2 was significantly elevated in the depressed group, and prostaglandin E1 showed a trend in the same direction. Lymphocyte stimulation responses, as measured by phytohemagglutinin, concanavalin A, and pokeweed mitogen, were significantly lower in the depressed group. Helper and suppressor T cell percentages did not significantly differ in the two populations. In the depressed group, prostaglandin E1 showed a significant inverse correlation with concanavalin A, and prostaglandin E2 showed a similar trend. These preliminary data suggest prostaglandins of the E series may be related to abnormalities of cellular immunity previously documented in depression.

MMPI assessment of patients with functional bowel disorders

This prospective study was undertaken to assess personality differences among patients with chronic pelvic floor disorders. Sixty patients (43 females and 17 males) of a mean age of 58 (range, 33–87) years with fecal incontinence (n=19), constipation (n=30), or levator spasm (n=11) had a mean duration of symptoms of 35 (range, 2–50) years. The Minnesota Multiphasic Personality Inventory (MMPI) was utilized for psychologic assessment for all patients prior to treatment. Mean scores for scales 1 (hypochondriasis), 2 (depression), and 3 (hysteria) were significantly elevated for the levator spasm group (71, 75, and 73, respectively). A similar pattern was seen for the constipation group, where the mean scores for scales 1 and 2 were significantly elevated (70 and 74, respectively) with a moderate elevation on scale 3 (68). The hypochondriasis (1), depression (2), and hysteria (3) scales are referred to as the “neurotic triad”, and profile patterns such as these indicate that these subjects may manifest their psychologic distress as physical symptoms. By contrast, the fecal incontinence patients were within the normal range on all scales. The information from these MMPI profiles can be used to understand the personality and emotional composition of these patients to assist in their evaluation and treatment.

Psychological responses to the implantable defibrillator: Preliminary observations

Among recent technologic advances in cardiology is the implantable cardioverter-defibrillator, introduced to control otherwise malignant tachyarrhythmia. This article describes psychological aspects of its use in 18 patients. Despite pre-implant anxiety, most eventually adapted well and accepted the device, with the level of adaptation relating primarily to severity of illness and the ability to return to work. Common problems that decreased over time included emotional lability, depression, fear, and hyperarousal with night wakefulness. Helpful treatment interventions included education, individual and family counseling, and relaxation techniques.

Psychotropics during pregnancy and lactation: A review

Abstract The literature dealing with prescription of psychotropics to the pregnant or lactating patient is principally retrospective, anecdotal to some extent, and often not current. Our review suggests that the data available can best be classified in relation to drug category (lithium, tricyclic antidepressant, antipsychotic, benzodiazepines), and to verified or presumed effects during the stage of pregnancy or lactation (first trimester, second and third trimesters, immediately before and after delivery, and during breastfeeding if that is allowable). By relating the data so classified to the urgency of the patients need for psychotropic treatment, the physician can strive for an optimal benefit-to-risk decision in what at present is one of the most unclear and difficult areas of psychiatric drug prescription.

Home Parenteral Nutrition for the Short Bowel Syndrome Psychological Issues

Home parenteral nutrition (HPN) for the short bowel syndrome represents a treatment modality that raises issues about prolonged machine dependency for living. Psychological reactions are described for patients with inflammatory bowel disorders and anatomical loss of small bowel. Liaison psychiatry involvement with 50 patients in the HPN program has identified such problems as grief reactions, depression, organic brain syndromes, drug dependency, and body image changes as they influence the initial adjustment to the in-hospital phase of HPN learning for patient and family. The importance of family and mental status examination are emphasized in the evaluation of the patient before and during the institution of an PHN program. Outlined are psychological parameters that need to be considered when assessing what factors might impede or enhance the acquisition and use of HPN information.

Home Parenteral Nutrition

Home parenteral nutrition is a life-sustaining mode of therapy for patients with short bowel syndrome that is unresponsive to conventional therapy. It requires learning specialized skills through an intensive training program and carefully following this program in a home setting. This training can be best provided by a group of health care specialists including a physician, nurse, dietitian, psychiatrist, social worker, and pharmacist who are knowledgeable about the issues that face the patient requiring home parenteral nutrition. The resources of career medical centers ar most appropriately utilized to provide the support needed to successfully undertake a home parenteral nutrition program. The nutritional requirements of these truly long-term patients have to be more accurately defined to guarantee that macronutrient and micronutrient requirements are being adequately provided for over the many years of required treatment. Fluid delivery systems and techniques for infection-free long-term venous catheterization have to be perfected. Home parenteral nutrition is a valuable life support system for patients with gut failure. Although expensive, it costs substantially less than in-hospital parenteral nutrition and can return the patient to a near normal life at home.

Noncompliance in younger adults on hemodialysis.

Abstract Study of noncompliance with maintenance hemodialysis by 111 patients revealed that 88% of the younger patients (ages 19 to 34) were noncompliant, as compared with 41% of the others (ages 35 to 79). Furthermore, the mean noncompliance score in the younger group was higher (23% vs 15%). Interviews and ratings showed that the younger patients had more difficulty with restrictions and less tolerance for frustration. Their problems of compliance may be intensified by the combination of the need to cope with chronic disease and the developmental pressures of early adult years. Timely psychiatric intervention should be undertaken to aid in better adjustment to a life-threatening illness.

Continuous ambulatory peritoneal dialysis: Psychological factors

Abstract Although time-consuming and a tedious task for the patient, continuous ambulatory peritoneal dialysis offers the prospect of greater independence, and enables the patient to take an active role in his or her own treatment. Little has been published on examination of those psychological factors indicative of a patients future success in accommodating to and complying with this demanding procedure. Based on our work with 46 patients, we define key factors for consideration, namely, mood, ability to test reality, cognitive function, body image, previous ability to handle crises, tolerance for environmental stress, personality structure, and acceptance of the treatment by relatives.

The neonatal narcotic abstinence syndrome: a brief review.

Because substance abuse experts are not available in many institutions, the consulting psychiatrist is required to diagnose and manage conditions such as the neonatal narcotic abstinence syndrome, which is readily recognized and treated. The authors discuss morbidity due to this syndrome in neonates born to narcotic addicted mothers. The clinical usefulness of neonatal narcotic abstinence scales is reviewed, with special reference to their application in treatment. The dosing of various drugs currently in use is also discussed.

Liaison Psychiatry Approach to Curriculum Development

Readily identifiable psychosocial problems exist which affect 50 to 75 percent of all hospitalized patients. The primary physician must learn to deal with these problems, frequently trial and error, “common sense,” or “role-modeling.” A training program at the University of South Dakota School of Medicine entitled LIAISON PSYCHIATRY was designed to help medical students recognize and handle these common problems.