Philip R. Muskin

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.

Psychiatric Evaluation of Mental Capacity in the General Hospital: A Significant Teaching Opportunity

Background Requests for evaluation of mental capacity in general hospitals have increased in frequency. Objective The authors sought to determine the interventions required to respond adequately and assess the initiating circumstances. Method Questionnaires completed by psychiatric consultants were analyzed, and chart reviews were completed. Results Capacity evaluation alone resolved 32% of the requests; 31% required an evaluation plus additional interventions; 37% did not require a capacity evaluation. Patients threatening to leave against advice, and/or refusing treatments or procedures represented 64% of requests. Consultants successfully resolved 88% of such cases. Conclusion A mental capacity evaluation alone was insufficient to resolve two-thirds of problems eliciting requests. Consultation–liaison psychiatrists can use these evaluations as teaching opportunities.

S -Adenosylmethionine (SAMe) for Neuropsychiatric Disorders: A Clinician-Oriented Review of Research

OBJECTIVE A systematic review on S-adenosylmethionine (SAMe) for treatment of neuropsychiatric conditions and comorbid medical conditions. DATA SOURCES Searches were conducted in PubMed, EMBASE, PsycINFO, Cochrane Library, CINAHL, and Google Scholar databases between July 15, 2015, and September 28, 2016, by combining search terms for SAMe (s-adenosyl methionine or s-adenosyl-l-methionine) with terms for relevant disease states (major depressive disorder, MDD, depression, perinatal depression, human immunodeficiency virus, HIV, Parkinsons, Alzheimers, dementia, anxiety, schizophrenia, psychotic, 22q11.2, substance abuse, fibromyalgia, osteoarthritis, hepatitis, or cirrhosis). Additional studies were identified from prior literature. Ongoing clinical trials were identified through clinical trial registries. STUDY SELECTION Of the 174 records retrieved, 21 were excluded, as they were not original investigations. An additional 21 records were excluded for falling outside the scope of this review. Of the 132 studies included in this review, 115 were clinical trials and 17 were preclinical studies. DATA EXTRACTION A wide range of studies was included in this review to capture information that would be of interest to psychiatrists in clinical practice. RESULTS This review of SAMe in the treatment of major depressive disorder found promising but limited evidence of efficacy and safety to support its use as a monotherapy and as an augmentation for other antidepressants. Additionally, preliminary evidence suggests that SAMe may ameliorate symptoms in certain neurocognitive, substance use, and psychotic disorders and comorbid medical conditions. CONCLUSIONS S-adenosylmethionine holds promise as a treatment for multiple neuropsychiatric conditions, but the body of evidence has limitations. The encouraging findings support further study of SAMe in both psychiatric and comorbid medical illnesses.

A pilot program for assigned reading by residents in consultation psychiatry

Abstract To increase the likelihood of their reading pertinent literature, the 27 residents in five consultation-liaison (C-L) training programs were required to present written responses to short-answer, examination-type questions derived from articles previously linked to a set of teaching objectives in C-L psychiatry. Questionnaire responses clearly indicated that all of the C-L service directors and about 75% of the residents found this approach to be of significant value in reading, remembering, and discussing assigned articles. This program is also recommended as a model for helping to train residents in other areas of psychiatry.

Psychosocial Issues in the Management of Patients with Tuberculosis

he resurgence of tuberculosis in the United States is due, in part, to the dismantling of large-scale T treatment systems that were a critical part of the disease control effort for the better part of the twentieth century.’ As the number of cases grows, clinicians, politicians, public health officials and community advocates have grappled with the difficult problem of building systems to care for infected people that are consonant with current knowledge and beliefs about quality care. As an example, the United Hospital Fund’s 1992 report, The Tuberculosis Revival: Individual and Societal Obligations in a Time of AIDS, discussed policies to guarantee adequate treatment that protects patients’ civil rights, needs for special facilities for care of TB patients, and the special problems faced by infected prisoners.* This thoughtful report highlighted many areas of social policy that require further examination. One such issue is the unmet psychosocial needs of patients with tuberculosis. Tuberculosis is most prevalent among groups of people likely to have psychosocial problems. These groups include the homeless) intravenous drug users, prisoners, recent immigrants, and those living in poverty and overcrowded h ~ u s i n g . ~ These problems may interfere with patient compliance, thus influencing the course of treatment. This is underscored by the data reported by Brudney and Dobkin, who interviewed all patients newly diagnosed withTB at Harlem Hospital from January 1,1988, through September 30, 1 9 m 4 Among the 224 people interviewed, 53 percent were alcoholic, 45 percent were homeless) 32 percent were unstably housed, 40 percent had AIDS or ARC. Homelessness and alcoholism were significantly associated with noncompliance. Patients with AIDSIARC were significantly less likely to be noncompliant (0.08; 0.02-0.34) except among those AIDS/ ARC patients who were homeless: 85 percent of the AIDS/ ARC patients lost to follow-up were homeless. All crack users were noncompliant. Brudney and Dobkin argue that neither homelessness nor addictive disorders is adequately addressed by existing health and social systems. It follows that, in order to improve patient compliance, these psychosocial needs must be addressed by treatment systems. This was recognized by Bayer, Dubler and Landesman in an overview of the ethical and policy issues raised by the resurgent TB epidemic.5 They noted, “An effective plan [for post-hospital care of tuberculosis patients] should include the provision of a secure residence with a range of social services and treatment options appropriate for each patient. Individuals with substance abuse problems must be encouraged to participate in and be guaranteed access to appropriate inpatient or outpatient treatment. Those with major psychiatric disorders must be offered appropriate clinical management.”6 As suggested by Bayer and colleagues, a wide range of problems fall under the heading of psychosocial problems. For example, high rates of psychiatric illness are found among the homeless, as well as among drug users, two groups likely to be noncompliant with TB medication. One may infer, therefore, that psychiatric illness may be com-

The Neuropsychiatry of Headache: Somatoform disorders and headache

This chapter focuses on the issues that arise when prescribing opioids and other controlled substances for chronic headache pain. The majority of headache patients who overuse or develop dependence on opioids and opioid-containing compounds suffer from migraine-type headaches. Tramadol withdrawal often includes symptoms not typically seen in pure opioid withdrawal, such as extreme anxiety, panic or paranoia, hallucinations, and feelings of numbness and tingling in extremities. Butorphanol, an opioid with partial mu-agonist effects, was first developed in injectable form and initially used in hospital settings mainly for post-operative and labor pain. The only barbiturate indicated specifically for the treatment of headache is butalbital, prescribed in the various combination medications. The care of cannabis-using patients may be managed best by coordinating their continuing headache care with an addiction specialist. It is well known that patients with physiologic dependence on caffeine routinely develop caffeine withdrawal headaches.

Psychiatric Issues in the Care of the Elderly Cardiothoracic Surgery Patient

Psychological and psychiatric issues that arise in the setting of major surgery for the elderly patient are both challenging and complex. The psychological implications of cardiothoracic surgery, the meaning of the operation in the context of the patient’s life, will vary from person to person. There are numerous potential complications caused by normal age-related changes in physiology that may affect the patient’s mental status and cause or exacerbate psychiatric conditions. The patient’s social environment, including how he or she affects and is affected by interpersonal exchanges with family and staff, will also impact on the preoperative and postoperative phases. This chapter will focus on common influences on geriatric patients’ mental health, including social relations, character structure and coping methods, vulnerability to the emotional and cognitive sequelae of surgery, underlying psychiatric conditions, and adverse responses to medication. In addition to the discussion of diagnoses, therapeutic interventions will be suggested, including psychotherapeutic, systems-oriented, and pharmacological treatments.