George Voineskos

PRN medication for psychiatric inpatients.

Little is known about the extent of the use of prn psychotropic medication in psychiatric inpatient units. A survey of the prn prescription and administration of psychotropic drugs in a psychiatric teaching hospital revealed that a large number of inpatients were prescribed and administered such drugs on a prn basis. Although 50% of the prescriptions were never administered, only 25% were actively discontinued by physicians. A diagnosis of personality disorder was the factor most frequently associated with the rate of prn prescriptions and of administrations. A large number of prn prescriptions had no instructions for indications, minimum time spacing between doses or maximum daily dosage. It is suggested that hospitals monitor the prn use of psychotropic medications in their inpatient units, and explore the reasons for such use. Psychotropic drug use on a prn basis should preferably be reserved for emergencies, and the instructions of prn prescriptions should be clear and detailed.

The psychiatric training of medical students.

Undergraduate psychiatric education should be concerned mostly with those aspects of psychiatry required for the proper practice of medicine. Psychiatric concepts and techniques are applicable to all medical practice and relevant to the daily work of every physician or surgeon. Therefore, in the psychiatric training of medical students the focus should be primarily on teaching “psychiatry of medical practice” and much less on teaching “specialty psychiatry. “ The teaching of psychiatry for medical practice will be best accomplished by selecting patients who are more like those the student will see later on as a practising physician. A systematic effort should be made to develop joint teaching with other departments, if we are to hope that students will carry over the approach we teach them to other subjects of medicine. Counselling and psychotherapy are essential skills for every physician or surgeon; medical students should be taught these skills by psychiatrists who are not just skilled psychotherapists but are also comfortable in their role as physicians in view of the importance of this role for the development of the identity of the medical student as a physician. The quality of the psychiatric training of medical students is dependent to a large extent on the priority accorded to undergraduate teaching by the department of psychiatry; competing activities, however, can result in undergraduate teaching being given less than top priority. Long-standing difficulties which psychiatry and psychiatrists experience in the medical school may impede undergraduate psychiatric education; these difficulties can be lessened by the closer involvement of psychiatrists with other physicians in the clinical and educational programs.

The introduction of a crisis unit in a mental hospital

A community oriented Crisis Unit was introduced in a mental hospital as an integral part of a comprehensive Clinical Service. The unit is doing crisis assessment and intervention for patients referred to this Clinical Service and a 72-hour inpatient or day-care crisis oriented therapy. The locale, the organization of the team and the work of the unit are described. Data are given regarding the number of patients seen during the first six months, of those admitted and of those discharged within 72 hours or transferred to another unit of the service. Additional data referring to the patients admitted to the Crisis Unit and during a corresponding six-month period of the previous year when the Unit was not operating are also given. The reduction of the inpatient population of the service and the associated financial savings are outlined. The management of the Unit on an open-door policy is described. The impact of the Unit on the treatment programs of the other units of the service is discussed. It is suggested that crisis therapy oriented units should be considered an essential and integral component of the psychiatric services offered by mental or general hospitals. Comparative studies of patient populations before and after the introduction of such units and long-term follow-up evaluative studies are required.

Book Review: Emergency Psychiatry: Crisis Intervention and Counseling by Telephone. 2nd EditionCrisis Intervention and Counseling by Telephone. 2nd edition. LesterDavid, editor. Springfield (IL): Charles C Thomas; 2002. 306 p. US

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The frequency with which prognosis is made in psychiatry is not known. This paper reports a study of the frequency and content of prognosis as recorded by staff psychiatrists and residents in a psychiatric teaching hospital. In addition, a review was carried out on the use of prognosis in ten psychiatric textbooks. The findings suggest that closer attention should be given to the teaching of prognosis. There is a clear need to consider moving away from the close dependence of prognosis on diagnosis, and from the unidimensional view of prognosis. Reasons are given for developing a prognosis, and suggestions are made regarding the organization of the prognostic statement.