Joel J. Silverman

Medical disorders in the schizophrenic patient

Objective: The primary purpose of this review of medical disorders in the schizophrenic patient is to provide the clinician interested in Consultation/ Liaison psychiatry and psychosomatic issues a comprehensive and current review of the subject. Method: The authors used the Index Medicus and Medline to find recent review articles and research articles related to medical disorders in the schizophrenic patient. Also, the authors described their clinical experience in Consultation/Liaison psychiatry working with schizophrenic patients in a large, tertiary-care academic medical center. Results: The authors divided their review into: 1) mortality and morbidity in schizophrenia, 2) differential diagnosis, 3) specific comorbidity management problems, 4) caring for schizophrenics on medical/surgical wards, and 5) antipsychotic drugs in the medical setting. Schizophrenia remains an important subject for Consultation/Liaison psychiatrists. Conclusions: Schizophrenia and its protean manifestations confound the care of the medical patient. The psychosis of schizophrenia may impair the patients capacity to recognize or articulate emerging medical illness, or to respond to therapeutic interventions. The psychiatrist caring for and consulting on patients with medical illnesses bears major responsibility for understanding the complex interface of schizophrenia and medical illnesses. Psychiatrists need to educate our medical and surgical colleagues how schizophrenia alters the usual presentation, clinical course, and response to treatment of common medical and surgical illnesses.

The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults

These Practice Guidelines for the Psychiatric Evaluation of Adults mark a transition in the American Psychiatric Association’s Practice Guidelines. Since the publication of the 2011 Institute of Medicine report Clinical Practice Guidelines We Can Trust, there has been an increasing focus on using clearly defined, transparent processes for rating the quality of evidence and the strength of the overall body of evidence in systematic reviews of the scientific literature. These guidelines were developed using a process intended to be consistent with the recommendations of the Institute of Medicine (2011), the Principles for theDevelopment of Specialty Society Clinical Guidelines of the Council of Medical Specialty Societies (2012), and the requirements of the Agency for Healthcare Research andQuality (AHRQ) for inclusion of a guideline in the National Guideline Clearinghouse. Parameters used for the guidelines’ systematic review are included with the full text of the guidelines; the development process is fully described in a document available on the APA website: http:// www.psychiatry.org/File%20Library/Practice/APA-GuidelineDevelopment-Process–updated-2011-.pdf. To supplement the expertise of members of the guideline work group, we used a “snowball” survey methodology to identify experts on psychiatric evaluation and solicit their input on aspects of the psychiatric evaluation that they saw as likely to improve specific patient outcomes (Yager 2014). Results of this expert survey are included with the full text of the practice guideline.

Clinical significance of tricyclic antidepressant plasma levels

Abstract Review of the literature indicates that measurements of tricyclic antidepressant plasma levels have great potential for clinical application. Their use is currently limited mainly by the difficulty in obtaining quality laboratory determinations in most geographic areas. Plasma levels are most valuable in treatment of patients who have problems with lack of response to the drugs, placebo response, noncompliance, multidrug effects, and changes associated with aging. Clinical application of steady-state plasma level ranges should be limited to patients with endogenous depression, since data are very limited for other varieties of depressive illness.

Challenges and Opportunities for Consultation-Liaison Psychiatry in the Managed Care Environment

While the evolving managed care revolution is dramatically changing the clinical, educational, and economic systems in which consultation-liaison (C-L) psychiatrists must operate, this revolution also present several important opportunities for those in C-L psychiatry. The authors, who are academic department chairs and formerly directed C-L divisions, discuss C-L psychiatrys potential involvement and suggest approaches to effectively address key aspects of these changes.

A survey of consultation-liaison psychiatry program characteristics and functions

A survey of medical school affiliated consultation-liaison psychiatry programs has provided useful information on several aspects of current C-L program activity, including: (a) patients seen and treatments provided; (b) C-L training; (c) program structure (and fiscal operations); and (d) subjective appraisal by program directors. Data on patients, diagnostic categories, and treatments support the findings of similar, previous studies. Training and research appear to be continuing at past levels rather than increasing. Limited information on fiscal operations and program structure preclude adequate assessment of their strengths and vulnerabilities. Recording of better data and the development of more aggressive management techniques are proposed as appropriate foci of attention for C-L program leaders.

The interim chairman role

Serving as interim chairman of an academic medical department is a challenging position, and one that is potentially rewarding despite the generally negative perceptions of the role. The authors present a framework categorizing different types of interim chairman positions, based on: 1) the qualifications and motivation of the individual; and 2) the goals and priorities of the institutions of power, i.e., university and hospital. The paper also delineates the stages of the interim chairman position, beginning with and emphasizing the importance of active preparation before taking office.

Adapting to decreased industry support of CME: lifelong education in an "industry-lite" world.

The continuing medical education (CME) enterprise in academic medicine is changing rapidly because of a number of important factors: the change in CME doctrine promulgated by the Accreditation Council for Continuing Medical Education (ACCME) (1), the refinement of the criteria for maintenance of certification (MOC) by the American Board of Medical Specialties (ABMS) (2), and alterations in patterns of commercial sponsorship for educational events by pharmaceutical and device industries. This article focuses on how alterations in the patterns of commercial support for educational events at academic medical centers and universities are changing the CME opportunities for faculty and trainees associated with academic departments of psychiatry. Historically, commercial funding has subsidized and supported considerable CME activity in academic medical centers. A 2006 survey (3) indicated that 49% of CME course costs at academic centers were funded by industry. Commercial sponsorship of CME has taken several forms. Commercial companies, either directly or through their educational intermediaries, have sponsored Grand Rounds speakers in academic departments, either as members of speakers’ bureaus or via individual grants. These companies have also helped underwrite the costs of CME conferences sponsored by academic departments through their universities. Also, commercial companies have sponsored journal clubs and dinner meetings with speakers for practitioners in the community, often at reasonably attractive restaurants, as well as travel funds for faculty, residents, and fellows to attend national and international meetings. Through “medical education and communication companies,” which have frequently partnered with academic departments of psychiatry, industry has sponsored educational activities with online options, teleconferences, and videoconferences and the development and production of CME events in conjunction with professional-association meetings. Traditionally, these offerings feature top names and excellent media production, and they draw large audiences. Thus, increased levels of commercial support have helped proliferate different approaches for physicians to receive free CME. At times, these presentations may become vehicles for commercial entities to “educate” practitioners in a manner that is conducive to acceptance of a product or a specific class of agents for treatment interventions. In 2008, pharmaceutical and medical-device companies funded half of the

Eighteen‐month follow‐up of neuropsychiatric effects of pentaborane intoxication

3 billion CME industry, and much of this money was directed to for-profit medical-communication companies that organize CME programs and symposia (4). Well-warranted concerns about ethics issues and the educational implications of marketing biases and academic leaders’ industry ties (5), raised by public scrutiny, Congressional investigations, and leaders in the medical profession, have led pharmaceutical and device companies to revise their funding patterns and practices. The overall effect has been a severe curtailment of industry funding of CME activities. Academic departments and organizations that relied on commercial largess have been increasingly deprived of the funds previously available for CME activities. According to industry sources, many providers now Received December 20, 2009; revised March 7, 2010; accepted March 8, 2010. Dr. Yager is affiliated with the Department of Psychiatry at the University of Colorado, Denver. Dr. Silverman is affiliated with the Department of Psychiatry at Virginia Commonwealth University in Richmond, VA. Dr. Rapaport is at the Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center, and the Department of Psychiatry and Bio-Behavioral Sciences, University of California, Los Angeles. Address correspondence to Joel Yager, Department of Psychiatry, University of Colorado, 13001 E 17th Pl, A011-04, Aurora, CO 80045; jyager@unm.edu (e-mail). Copyright

The validity of psychiatric diagnosis under conditions of physical trauma: a pilot study

Fourteen individuals briefly exposed to the neurotoxic compound Pentaborane were reevaluated 18 months following initial neurpsychiatric study. Psychiatric interview utilizing standardized diagnostic criteria, neuropsychological and psychological assessment, and CT scan ventricular brain ratios were reevaluated. Assessment revealed interaction of bilogical and psychological factors worsening. Post-traumatic stress disorder, major affective disorder, alcohol abuse, and phobias were the most common diagnoses at follow-up.

Psychopathology in Medical Inpatients and its Relationship to Length of Hospital Stay: A Pilot Study

The validity of psychiatric diagnosis obtained from hospitalized trauma patients was investigated to determine whether hospitalization with associated pain, discomfort, and medication artificially inflated the estimated prevalence of psychiatric diagnoses. Diagnostic Interview Schedule results from eleven hospitalized patients were compared with those obtained from the same patients after discharge. Diagnoses were found to be consistent for eight of eleven patients and eleven of fifteen diagnoses remained unchanged. This study yielded no evidence that recent trauma and hospitalization significantly influenced the initial psychiatric diagnoses obtained using the DIS.