Jeffrey L. Houpt

Perception of Poor Health in the Healthy Older Adult

ABSTRACT: A survey of 977 community subjects aged 65 or older identified 719 of them as not impaired in physical health. Of these, 104 (14 percent) perceived their physical status to be poor, whereas 615 (86 percent) accurately perceived it to be unimpaired. There were no significant differences between the two groups with regard to age, sex, race, social class, living arrangements and number of drugs used. The physically healthy elderly who perceived their physical status to be poor were more depressed, more hypochondriacal, and more dissatisfied with life. They tended to complain of multiple symptoms; activities of daily living were decreased, and they were more likely to visit their doctor frequently during the year (analysis controlled for physical health in each case). Mental health was slightly but significantly more impaired in these subjects; nevertheless, they were more likely to seek the help of a trained counselor. The findings suggest that a self‐perception of poor health among the physically healthy elderly may represent a generalized request for attention from trained personnel in the social environment.

Masked depression in a combined medical-psychiatric unit

Abstract The authors describe experience with over 200 patients in a combined medical-psychiatric unit. A minority (17%) of patients carried the diagnosis of a depressive disorder on admission, but after an intensive psychiatric evaluation, over half received a depression-related diagnosis. The majority of patients had initially presented to their internists with somatic complaints. These observations reiterate previous observations that significant numbers of patients have depression that may be under-recognized because of the presence of somatic symptoms and the prominent use of denial, repression, and obsessive-compulsive defenses. Implications for the relative cost-effectiveness of treating these patients in an inpatient seuing as contrasted to outpatient and liaison models are also discussed.

The Application of Competency-Based Education to Consultation-Liaison Psychiatry: I. Data Gathering and Case Formulation

In the first of three papers, the authors present a competency-based model for training in consultation-liaison psychiatry which addresses the issues of how residents are taught to collect and formulate patient data. This model emphasizes the use of behavioral statements to describe the process of how a consultation is done. By comparing the residents performance with prestated behavioral objectives, a method for residency supervision is offered. The second paper carries this one step further with the application of the model to clinical intervention strategies. The final paper discusses the implications of this approach to some of the issues that surround residency training in this field.

Chronic low back pain and depression

Abstract In an attempt to clarify the relationship between chronic low back pain and depression, the authors studied the incidence of depression, alcoholism, and chronic back pain in first-degree relatives of chronic pain patients with and without depression. A higher incidence of recurrent unipolar depression was found in those relatives of patients with depression than without depression. These findings raise questions about the concept of chronic low back pain simply as a variant of depression and they suggest that the occurrence of major depression together with chronic back pain might relate to genetic vulnerability to depression.

Central nervous system sarcoidosis

Sarcoidosis may involve the central nervous system (CNS) in approximately 5% of cases. Three levels of neurological involvement are possible and include cranial nerve abnormalities, peripheral neuropathies, and lesions of the brain, spinal cord, and meninges. In addition to abnormal neurological findings, psychiatric presentations of CNS sarcoidosis include symptoms of delirium, dementia, depression, personality changes, and psychosis. The diagnosis usually rests on neurological, psychiatry, and cerebrospinal fluid (CSF) abnormalities with a history of sarcoidosis in other organ systems. The CSF, however, may be normal in as many as 30% of cases. The complexities of the illness and the difficulties that may be encountered in making the diagnosis are illustrated with a case of suspected CNS sarcoidosis that presented with delirium and choreoathetosis. The use of steroids as the mainstay of treatment is also discussed.

Evaluating liaison program effectiveness: the use of unobtrusive measurement.

The author suggests that the goal of liaison psychiatry as well as its organizational and clinical properties require the use of measures which are non-reactive and developmental in nature. In this paper four categories are theorized as representing the implicit working assumptions of nonpsychiatric housestaff in clinical formulation. By analyzing the overt and latent assumptions of the questions presented to a liaison psychiatrist in patient care conferences, the author illustrates how the assumptions can change through six levels of development. Changes within the assumptions are then used as criteria for program effectiveness since the working assumptions represent preconditions to holistic care. Potential uses of this global scheme for evaluating liaison programs are suggested.

Interictal schizophrenia-like psychoses in temporal lobe epilepsy

Abstract Interictal schizophrenia-like psychotic episodes may occur in association with temporal lobe seizure disorders. The search for a link between temporal lobe epilepsy (TLE) and these interictal episodes has been approached from several theoretical perspectives, and includes (1) the “antagonistic theory” based on the apparent inverse relationship between seizures and psychosis, (2) significance of the neuroanatomic location of the seizure foci, (3) possible adverse effects of anticonvulsants, (4) excess or deficiency of certain neurotransmitters, and (5) pathologic effects on behavior of repeated electrical stimulation of the brain (kindling). These theories and their treatment implications are discussed.

Models for evaluating teaching in consultation-liaison psychiatry

This paper reviews the purposes and methodologic requirements of conclusion-oriented research for evaluating outcomes of consultation-liaison (C-L) teaching in psychiatry. Requirements for replicating educational methods and outcomes, and for demonstrating cause-effect relationships between program inputs and program outcomes include: careful definition of educational methods; selection of valid and reliable outcome measures; and use of sound experimental designs. Barriers to meeting these methodologic criteria in C-L settings are identified, and methods for overcoming them are suggested. In addition, useful guidelines are provided for the educator wishing to conduct conclusion-oriented C-L research to determine teaching effectiveness.

Models for evaluating teaching in consultation-liaison psychiatry: II. Decision-oriented research.

The authors present a Program Audit Form (PAF), which can be used to evaluate liaison programs. Use of PAF illustrates the decision-oriented approach to evaluative research defined in Part I of this paper. The PAF includes three categories of information about the liaison program: (a) administrative arrangements, (b) program description, and (c) program feed-back. The information will provide the user with an overall picture of a Programs weaknesses and strengths, and a basis for making decisions about program change. The form is short and represents the minimal data program directors should have readily available without requiring technician time or research expense. Finally, it can be used to compare programs across institutions, because it includes descriptors of administrative arrangements.

The Application of Competency-Based Education to Consultation-Liaison Psychiatry: II. Intervention Knowledge and Skills

Although psychological and pharmacological intervention is an important aspect of the treatment of patients seen in consultation on medical and surgical wards, little attention has been directed to the method of training psychiatric residents in these areas. In this paper, the authors continue the application of the competency-based model of training to the problems of clinical intervention. Behavioral objectives are presented as a focus for residency supervision and their application to a clinical situation is illustrated. The objectives are designed to consider the activities of the consulting psychiatrist as he relates to the patient as well as other members of the treatment milieu.