Thomas J. Craig

Antipsychotic drug use and birth defects: an epidemiologic reassessment.

Abstract A reassessment of studies concerned with the possible teratogenic effect of neuroleptic medication using the test-based approach of Miettinen suggests a possible increase in birth defects among children born of mothers first exposed to drugs during the sixth to tenth week of gestation. In view of the epidemiologic inadequacies of earlier studies which suggest no increased teratogenic effect of these drugs, caution should be used in their prescription during this stage of gestation. Further work is indicated using appropriate epidemiological techniques and multivariate statistical methodology to determine the true effect of these drugs in pregnant psychotic women.

An epidemiologic study of a psychiatric liaison service

An epidemiologic study of 308 consultations revealed substantial differences in referral rates related to the demographic, clinical, and programmatic characteristics of patients and services. Actual liaison was associated with substantially increased referral rates across all age groups. Female patients appeared to have differentially benefited by liaison activities in terms of obtaining appropriate psychiatric intervention. Across all services studied (medicine, neurology, surgery, and obstetrics/gynecology), consultation appeared mainly directed at establishing a specific psychiatric diagnosis and treatment. Markedly different patterns of emotional disturbance were noted across different medical disease categories (e.g., cancer, chronic renal disease).

Cancer and mental illness

Abstract The relationship between mental illness and neoplastic disease has been the subject of controversy for decades. 1–3 Early studies using proportionate mortality rates (i.e., the proportion of cancer deaths to total deaths in a given population) were interpreted as evidence that psychotic patients have a significantly lower rate of cancer than the general population. 3–5 These studies have been extensively criticized on the grounds that since psychiatric patients tend to have increased mortality from a variety of causes (e.g., pneumonia) relative to the general population, if cancer mortality were more equal in incidence between patient and general population groups, the proportionate mortality data would spuriously suggest reduced cancer risk among patients. 4–6 Other reports using age specific or age adjusted mortality data, with three exceptions, 7–9 have indicated an equal or slightly increased incidence of cancer mortality among psychiatric patients as compared to the general population. 4–6,10–15 However, several of these studies have suggested that the relative risk of cancer is greater among female patients than among male patients, with male patients having relative risk equal to or less than the male general population. 11–13,15 In addition, a number of reports have commented that paranoid schizophrenics have an increased risk for cancer while other categories of schizophrenia are associated with reduced risk. 1,4,5 To our knowledge, this hypothesis has not been further replicated. To complicate the picture, recent reports have raised the question of whether neuroleptic treatment might predispose to breast cancer through its dopamine blocking effect of raising serum prolactin. 16,17 Virtually none of the studies examines cancer rates by age, sex, and diagnosis, however; thus there is little opportunity to identify more subtle trends. The present study, part of a larger study of mortality among psychiatric inpatients, provided the opportunity to investigate these issues in a relatively large sample.

Mortality among Elderly Psychiatric Patients: Basis for Preventive Intervention

ABSTRACT: Analysis of cause‐specific death rates among 750 elderly psychiatric inpatients revealed a markedly increased risk of death from pneumonia and a lesser but still substantial risk of death from cardiovascular disorders during the first year of hospitalization. Although the risks of cardiovascular death are considerably less among longer‐stay patients, the pneumonia risks remain high. This suggests differing preventive strategies. To help prevent cardiovascular deaths, more attention should be paid to avoiding transfer trauma and its attendant stress. To help prevent pneumonia deaths, high priority should be given to an aggressive program of immunization, adequate nutrition, reduction of hospital overcrowding, and recognition of early pneumonia symptoms.

Trends in the presription of psychotropic drugs (1970–1977) in a state hospital

Abstract Analysis of prescribing patterns in a state hospital over an 8-yr period (1970–1977) revealed a significant reduction in the use of piperidine and piperazine neuroleptics and tricyclic antidepressants with an increase in use of butyrophenones and lithium. By 1977, prescribing patterns for men and women were virtually identical. Almost one-third of the patients (chiefly long stay and elderly) were receiving no psychotropic medications. The patterns of medication use over time contrasted strongly with patterns reported among nedical patients and the general population and suggest increasing restraint and a trend toward more appropriate pharmacotherapy in this setting, which may be attributable in part to an active educational program combined with a computerized drug exception system.

Medication use and mortality

Abstract A logistic regression analysis of the association among specific causes of mortality and indices of psychotropic medication use was carried out among 722 psychiatric inpatient deaths and age, sex, diagnosis, and length of stay matched controls. Overall findings revealed remarkably few significant associations between death and drug use. Of the significant findings, an increased proportion of dead patients in three categories were using piperidine phenothiazines at death while young male patients dying of heart disease tended to be receiving significantly higher average daily doses of medications with strong anticholinergic effects than controls, often in combination. On the positive side, elderly living patients tended to be receiving tricyclic antidepressants for longer durations than controls for several death categories, suggesting a possible beneficial effect of medication use.

Pneumonia and Psychotropic Drug Use in Elderly Psychiatric Patients

A study of the use of psychotropic drugs among 30 elderly psychiatric patients with pneumonia (15 of whom died), in comparison to the general elderly population of the hospital, revealed a negative association between the use of psychotropic agents and the development of pneumonia. The factors of age, sex, pre‐existing illness, and organism virulence/patient resistance were all associated with death from pneumonia. However, the present findings do not support the hypothesis that psychotropic drugs are implicated in pneumonia deaths among elderly psychiatric patients.

Pharmacotherapy of the hospitalized young adult schizophrenic patient

The authors surveyed pharmacotherapy in a group of hospitalized 18 to 35-year-old young adult patients (N = 286) with a DSM-III diagnosis of schizophrenia. Drug use comparisons were made between patients with a 180 day or less hospitalization (short-stay, N = 226) and those with a 366+ day hospitalization (long-stay, N = 60). Psychotropic drug usage during the initial 180 and most-recent 180 days of treatment of the long-stay group was compared with the total episode of the short-stay group. Antiepileptic, antidepressant, lithium and anxiolytic/sedative/hypnotic agents, were used in significantly more of the long-stay than short-stay patients. This increase was not observed between the two groups for the initial 180 days of the long-stay group but was observed during the most recent 180 days of treatment. Antipsychotic mean daily doses and patterns of use in the two length of stay groups were similar. Chlorpromazine (CPZ) dosage was significantly increased in long-stay patients compared with short-stay patients (P less than .05).

Recidivism and comprehensive care systems

Abstract The analysis of a one year followup of schizophrenic patients discharged from a state hospital revealed a remarkably low (17.8%) readmission rate among patients discharged to a comprehensive care system. In contrast, catchment area patients referred outside this system had a readmission rate (50%) similar to those reported for untreated schizophrenics. The latter group, representing less than 20% of the total patient group, was responsible for 50% of the readmissions. Effectiveness of the support system in preventing readmission may relate to a high rate of continuity of treatment in this group. The findings strongly suggest the extension of such support services to all treatment resources.

Ethical aspects of primary preventive measures among the institutionalized elderly.

For the interested physician, the primary prevention of medical illness if often considered a luxury or an optional exercise. This report illustrates the position that physicians caring for the institutionalized elderly have a strong ethical and perhaps legal obligation to institute primary preventive strategies, in view of their responsibility for total care of the patient. As an example related to cardiovascular mortality and morbidity, primary preventive strategies directed at cigarette smoking and immobilization appear to be clearly indicated. The absence of such preventive strategies could be construed as acceptance of intervention designed to increase morbidity and mortality.