Elisabeth J. S. Kunkel

Hematologic Side Effects of Psychotropics

Psychiatrists are often unaware of the potential hematologic complications of the psychotropics they prescribe. Although this review is not a hematologic text reference, relevant hematologic syndromes are described so that the consultation-liaison psychiatrist will be familiar with the usual signs, symptoms, and treatments of these syndromes. This article reviews the hematologic side effects of the commonly prescribed psychotropics, including antipsychotics, antidepressants, benzodiazepines, lithium, mood stabilizers (including some of the anticonvulsants), and the acetylcholinesterase inhibitors. Clinical signs and symptoms that should alert the physician to obtain a complete blood count are described.

The Academy of Psychosomatic Medicine Practice Guidelines for Psychiatric Consultation in the General Medical Setting

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.

Consultations for ‘Maladaptive Denial of Illness’ in Patients with Cancer: Psychiatric Disorders that Result in Noncompliance

Patients who present with late stages of cancer often have complicated medical and psychiatric problems which are labeled as ‘maladaptive delay or denial.’ In some of these patients, psychiatric problems have either contributed to the delay in medical presentation for care or have interfered with treatment of the late stage cancer. The authors review some of the factors that contributed to delay and noncompliance in a series of patients with cancer who were evaluated by the psychiatric consultation service of a university hospital. Specifically, psychoses and cognitive impairment played a major role in delay and noncompliance. The authors discuss recommendations for management of such patients, and suggest that clinicians often benefit from the assistance of the psychiatric consultant as part of the treatment team. Multiple resources and multiple types of intervention are needed in order to help such patients negotiate the clinical environment.

Psychiatrists for Medically Complex Patients : Bringing Value at the Physical Health and Mental Health/Substance-Use Disorder Interface

BACKGROUND In their current configuration, traditional reactive consultation-liaison services see a small percentage of the general-hospital patients who could benefit from their care. These services are poorly reimbursed and bring limited value in terms of clinical improvement and reduction in health-service use. METHOD The authors examine models of cross-disciplinary, integrated health services that have been shown to promote health and lower cost in medically-complex patients, those with complicated admixtures of physical, mental, social, and health-system difficulties. CONCLUSION Psychiatrists who specialize in the treatment of medically-complex patients must now consider a transition from traditional consultation to proactive, value-added programs and bill for services from medical, rather than behavioral, insurance dollars, since the majority of health-enhancement and cost-savings from these programs occur in the medical sector. The authors provide the clinical and financial arguments for such program-creation and the steps that can be taken as psychiatrists for medically-complex patients move to the next generation of interdisciplinary service.

African-American men and intention to adhere to recommended follow-up for an abnormal prostate cancer early detection examination result

OBJECTIVES To assess the intention of African-American men to have the recommended follow-up in the event of an abnormal prostate cancer early detection examination and to identify the variables that help to explain adherence intention. METHODS In the spring of 1995, we selected a random sample of 548 African-American men who were patients at the University of Chicago Health Service. The sample included men who were 40 to 70 years of age, did not have a personal history of prostate cancer, and had a working telephone number. A total of 413 men who completed the telephone survey received an invitation to consider undergoing a prostate cancer early detection examination. The survey provided data on personal background characteristics, knowledge, attitudes, and beliefs related to prostate cancer and early detection. Respondents were asked whether they would choose to have the recommended follow-up in the event of an abnormal early detection examination result. Univariate and multivariate analyses of intention to have follow-up were performed. RESULTS An intention to have the recommended follow-up was reported by 77% of the survey respondents. The results of multivariate analyses revealed that the intention to have the follow-up was positively associated with education beyond high school (odds ratio [OR] 1.9); perceived self-efficacy related to prostate cancer screening (OR 2.1); the belief that prostate cancer can be cured (OR 3.3); the belief that prostate cancer screening should be done in the absence of prostate problems (OR 2.3); and physician support for prostate cancer screening (OR 2.1). CONCLUSIONS African-American men who have a high school education or less may be at risk of nonadherence to recommended follow-up. Adherence also may be low among men who do not have favorable views of early detection or do not perceive strong physician support for early detection. Research is needed to determine whether intention and other factors predict actual adherence to follow-up in this population group.

Muscle Test Comparisons of Congruent and Incongruent Self-Referential Statements

This study investigated differences in values of manual muscle tests after exposure to congruent and incongruent semantic stimuli. Muscle testing with a computerized dynamometer was peformed on the deltoid muscle group of 89 healthy college students after repetitions of congruent (true) and incongruent (false) self-referential statements. The order in which statements were repeated was controlled by a counterbalanced design. The combined data showed that approximately 17% more total force over a 59% longer period of time could be endured when subjects repeated semantically congruent statements (p<.001). Order effects were not significant. Over-all, significant differences were found in muscle-test responses between congruent and incongruent semantic stimuli.

Changes in cerebral blood flow and anxiety associated with an 8-week mindfulness programme in women with breast cancer.

This study employed functional magnetic resonance imaging to evaluate changes in cerebral blood flow (CBF) associated with the Mindfulness-based Art Therapy (MBAT) programme and correlate such changes to stress and anxiety in women with breast cancer. Eighteen breast cancer patients were randomized to the MBAT or education control group. The patients received the diagnosis of breast cancer between 6 months and 3 years prior to enrollment and were not in active treatment. The age of participants ranged from 52 to 77 years. A voxel-based analysis was performed to assess differences at rest, during meditation and during a stress task. The anxiety sub-scale of the Symptoms Checklist-90-Revised was compared with changes in resting CBF before and after the programmes. Subjects in the MBAT arm demonstrated significant increases in CBF at rest and during meditation in multiple limbic regions, including the left insula, right amygdala, right hippocampus and bilateral caudate. Patients in the MBAT programme also had a significant correlation between increased CBF in the left caudate and decreased anxiety scores. In the MBAT group, responses to a stressful cue resulted in reduced activation of the posterior cingulate. The results demonstrate that the MBAT programme was associated with significant changes in CBF, which correlated with decreased anxiety over an 8-week period.

Psychosocial benefits of a novel mindfulness intervention versus standard support in distressed women with breast cancer.

It is well documented that stress is associated with negative health outcomes in cancer patients. The purpose of this study was to assess the effects of a novel mindfulness intervention called mindfulness‐based art therapy (MBAT) versus standard educational support, on indices of stress and quality of life in breast cancer patients with high stress levels.

Measuring Informed Decision Making about Prostate Cancer Screening in Primary Care

Purpose. To measure the extent of informed decision making (IDM) about prostate cancer screening in physician-patient encounters, describe the coding process, and assess the reliability of the IDM measure. Methods. Audiorecoded encounters of 146 older adult men and their primary care physicians were obtained in a randomized controlled trial of mediated decision support related to prostate cancer screening. Each encounter was dual coded for the presence or absence of 9 elements that reflect several important dimensions of IDM, such as information sharing, patient empowerment, and engaging patients in preference clarification. An IDM-9 score (range = 0–9) was determined for each encounter by summing the number of elements that were coded as present. Estimates of coding reliability and internal consistency were calculated. Results. Male patients tended to be white (59%), married (70%), and between the ages of 50 and 59 (70%). Physicians tended to be white (90%), male (74%), and have more than 10 years of practice experience (74%). IDM-9 scores ranged from 0 to 7.5 (mean [SD], 2.7 [2.1]). Reliability (0.90) and internal consistency (0.81) of the IDM-9 were both high. The IDM dimension observed most frequently was information sharing (74%), whereas the dimension least frequently observed was engagement in preference clarification (3.4%). Conclusions. In physician-patient encounters, the level of IDM concerning prostate cancer screening was low. The use of a dual-coding approach with audiorecorded encounters produced a measure of IDM that was reliable and internally consistent.

Behaviors Used by Men to Protect Themselves against Prostate Cancer

This paper reports on behaviors men use to protect themselves against prostate cancer. Data were collected via a telephone or mailed survey from 353 men enrolled in two studies of prostate cancer screening. Respondents reported behaviors they used to protect themselves against prostate cancer, and responses were coded as conventional care, self-care, or nothing. Men who reported using both conventional care and self-care were categorized as conventional care users. Polytomous logistic regression was conducted to evaluate the association between sociodemographic background, prior prostate screening, and cognitive, affective, and social support and influence factors with protective behavior type. The distribution of protective behaviors was as follows: conventional care, 63%; self-care only, 19%; and nothing, 18%. In multivariable analyses, higher education level was found to be positively associated with conventional care use. Perceived salience and coherence of prostate cancer screening was positively associated with conventional care use among men in one of the two studies. Low concern about screening was positively associated with self-care use, as was mailed survey completion. This study presents self-report data regarding prostate cancer protection behaviors. Most men in the study reported using some type of prostate cancer protective behavior. Decision-making about whether or not to take protective action and what type of behavior to use may be influenced by socioeconomic background, cognitive perceptions related to behavioral options, and concern about risk.