Wayne D. Mitchell

Underconsultation and lack of follow-up for alcohol abusers in a university hospital

Abstract In a prospective chart audit of university hospital medical inpatients, an alcohol-use history was not recorded in 22% of the charts. Alcohol abuse was recorded in 21% of them. A retrospective chart audit of patients previously discharged from the same wards revealed that psychiatric or other substance abuse consultation had been requested for only 21% of patients in whom a clear-cut alcohol abuse history had been obtained and recorded. These data suggest the need for more screening and consultation for alcohol abuse by primary care physicians and more involvement of consultation-liaison psychiatrists in the care of patients with alcohol abuse.

Some methodological issues in consultation-liaison psychiatry research

This is a research methodologic design model that may be useful to consultation-liaison psychiatrists. It is intended to facilitate such researchers in setting up and executing carefully controlled studies of the effectiveness (in psychiatric, medical, surgical, functional, cost, or other areas) of consultation-liaison interventions. The specific variables discussed are areas of particular interest to the authors, but many other variables may be readily substituted into this basic model. The design may be expanded or contracted relatively easily as would be appropriate for particular projects. The overall purpose of this paper is, hopefully, to serve as a catalyst for consultation-liaison psychiatrists to consider such research in their academic settings and to foster increased discussion and critical thinking regarding such research. The authors consider such research efforts important for the future regarding the scientific basis, proven effectiveness, and funding of consultation-liaison and general hospital psychiatry.

Treatment of hypertension in the elderly with a new calcium channel blocking drug, nitrendipine

PURPOSE Treatment of hypertension in the elderly decreases cardiovascular morbidity and mortality. We hypothesized that nitrendipine would be efficacious in the treatment of hypertension in the elderly. We evaluated potential differences between nitrendipine and the commonly used drug hydrochlorothiazide (HCTZ). PATIENTS AND METHODS The study was conducted as a double-blind randomized clinical trial of nitrendipine or HCTZ. Thirty hypertensive subjects over age 60 with a median sitting blood pressure greater than or equal to 95 mm of Hg were recruited into the study. A diastolic blood pressure with treatment of less than 95 mm Hg with a 5 mm Hg or greater decrease from baseline was considered a successful response. RESULTS Nitrendipine decreased mean (+/- SEM) blood pressure from 163 +/- 3/102 +/- 1 to 142 +/- 2/89 +/- 2 mm Hg, and HCTZ decreased it from 164 +/- 4/102 +/- 1 to 143 +/- 5/91 +/- 2 mm Hg. A greater proportion of patients had a successful response with nitrendipine (81 percent) than with HCTZ (64 percent). The antihypertensive effect of nitrendipine twice daily appeared to be sustained for 24 hours. Blood pressure response to exercise was attenuated with both drugs. HCTZ caused gout, leg pains, muscle aches, hypokalemia, increased uric acid levels, and increased total cholesterol and triglyceride levels. Nitrendipine caused edema and tachycardia. CONCLUSION Nitrendipine significantly reduces blood pressure with few side effects and no adverse metabolic effects, and offers a reasonable alternative for treating hypertension in the elderly.

Family Physicians' Perceptions of Psychosocial Disorders: Survey Report and Educational Implications

One-hundred seventy-seven family physicians were surveyed regarding their perceptions of the types of psychosocial problems encountered in their practices, the amount of time they felt they devoted to each problem, and their interests regarding continuing psychiatric education. Patients with “multiple somatic complaints” and “symptoms of emotional distress” were reported as being encountered most frequently. Marital and family problems, alcoholism and sexual dysfunction were also ranked highly. The physicians indicated the highest interest in managing these disorders in addition to treatment of the suicidal patient. The implications of these results for psychiatric educators and liaison psychiatrists are discussed. The authors recommend using DSM-III diagnostic criteria applicable to these syndromes in formulating educational programs for primary care physicians.

Primary Care Physicians’ Perceptions of Psychiatric Disorders and Treatment Approaches in Young and Middle-Aged Adult Patients

Two hundred thirty-four primary care physicians were surveyed concerning psychiatric disorders observed, treated, or referred among young and middle-aged adult patients in their practices. Responses were analyzed by age of physician, specialty, type of practice, and location of practice. The problems for which referrals or consultations were typically sought varied primarily by specialty and setting. Treatments utilized differed mainly by age, specialty, and setting. Sources of consultation and referral most often used varied depending on the respondents specialty, setting, and type of practice. The results suggest several areas of significant teaching opportunities for consultation-liaison psychiatrists with their primary care colleagues.

Effect of a Sustained-Release Formulation of Trimazosin in Mild to Moderate Hypertension

A single‐blind study was conducted to evaluate the blood pressure (BP) reduction and side effects of a sustained‐release (SR) formulation of trimazosin in patients with mild to moderate hypertension. Eighteen individuals (age, 21–65 yr; mean diastolic BP, >95 mm Hg) with essential hypertension were enrolled into the study. Each patients dose was titrated to a range of 150–900 mg/d, with polythiazide added as necessary to achieve BP control Four hours following the maximum titrated dose of trimazosin, mean standing and supine diastolic BPs were significantly lower than baseline readings. Supine systolic BP and supine and standing heart rate were not significantly lower than baseline. At 24 hours after administration of the maximum dose, there were no significant differences in heart rate or BP compared with baseline readings. Five of 16 patients responded to trimazosin therapy alone. Of the 11 treatment failures with trimazosin alone, five were therapeutic failures and six discontinued because of side effects. Only two of these 11 patients achieved satisfactory results with the combination therapy. Trimazosin SR acutely lowers BP three to six hours after administration. It appears to have a duration of action longer than six hours, but it is not sustained for 24 hours. The proportion of patients failing to respond in this sample was very high and suggests that for similar patients, the drug does not appear to be a very useful antihypertensive agent.

Research problems for consultation-liaison psychiatry in the DRG era

Psychiatry needs to conduct more rigorously designed empirical research studies to demonstrate its cost-effectiveness, especially since the DRG era is becoming more firmly established. The effectiveness of psychiatric intervention can be evaluated on its abilities to improve physical functioning as well as its improvement of psychosocial symptoms and cost savings. Some of the problems in consultation-liaison research are discussed, including the potentially confounding influences of demographic variables, type and severity of somatic disease, time since diagnosis, level of psychosocial stress, and initial level of physical functioning. Several types of research measures used in assessing physical and psychosocial functioning are discussed, and some of the dilemmas for psychiatry in utilizing individual versus standardized research interventions are explored.