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The major cause of cardiac mortality in the United States is sudden cardiac death, most often the result of ventricular tachycardia-ventricular fibrillation. Transient risk factors for sudden cardiac death include psychiatric conditions mediated through the CNS. Major advances in the evaluation and treatment of patients who have survived malignant ventricular arrhythmias have been accompanied by challenging management and therapy issues for the psychiatrist involved in the care of such patients. The authors suggest ways to meet these challenges, especially in the care of patients with concomitant anxiety, depression, delirium, or psychosis.
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PMID:Psychiatric aspects of patients with malignant ventricular arrhythmias. 353 12

Psychiatric disorders induced by drugs are of most concern when they occur in the context of therapeutic use of a drug. Such iatrogenic psychiatric disturbances may interfere considerably with the treatment of the primary illness and may cause concern to patients, their relatives and the medical staff. Because many drugs are often used simultaneously in seriously ill patients, it may be difficult to be sure which drug may have been responsible. The best procedure is to remove those drugs which are most probable causes of the psychiatric disturbances as well as any drugs that are not truly essential for the treatment of the patient. Problems involved in evaluating the relationship between use of drugs and psychiatric disorders are considerable. Many reports are isolated cases and the denominators which might provide some idea of the potential risk are unknown. Many relationships are still controversial, such as the association of depression with sedatives, antihypertensives and oral contraceptives. Areas of uncertainty are great. Psychomotor impairment may be caused by a drug that can alter consciousness, or any drugs that can produce more delineated psychiatric syndromes. Sedative drugs are those most commonly associated with psychomotor impairment, and may include psychotherapeutic drugs, sedative antihistamines, narcotic analgesics and, of course, the widely used social drug, alcohol. Delirious states are most often associated with drugs that possess central anticholinergic actions. These include not only drugs clearly identified as anticholinergics, but also tricyclic antidepressants and anti-Parkinson drugs. Cimetidine, which is often used parenterally in seriously ill patients, is also a prominent cause. Delirium is most often seen in elderly patients and in those who have received rather large doses of drugs. The association of schizophrenic-like psychoses with dopaminomimetic drugs tends to support the prevailing dopamine hypothesis of schizophrenia. Levodopa, the dopamine precursor, and bromocriptine, a direct dopamine agonist, are examples of such relationships. Abuse of social drugs has also been thought to provide a useful model of schizophrenia. Hallucinogens are probably a rather poor model, abuse of amphetamines may provide a better model, and possibly the best is the psychotic state elicited by phencyclidine. Manic reactions are clinically difficult to differentiate from schizophrenic-like psychoses and are often produced by similar drugs. Corticosteroids may produce either manic or schizophrenic-like disorders, as well as occasionally confusion and depression.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:Drug-induced psychiatric disorders and their management. 354 May 20

The psychiatric complications most often seen in cancer are depression, anxiety, and delirium. All are more likely to occur in the cancer patient who has pain. It is important for patient comfort and quality of life to evaluate and intervene to manage the psychologic distress in the patient with cancer, especially if pain is a complication.
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PMID:The cancer patient with pain: psychiatric complications and their management. 354 80

In a prospective study of hospitalized patients referred to a psychiatry consultation service, 46 patients were referred for a presumed diagnosis of depression because crying was a prominent symptom. Psychiatric consultation determined that 20% had a psychiatric disorder only, 33% had a neurological disorder only, 43% had both psychiatric and neurological disorders, and 4% had a previously undescribed entity, "essential" crying. The most common neurological disorder in these crying patients was bilateral hemispheric dysfunction associated with dementia or delirium; the most common psychiatric disorder was major depression. Effective therapy for patients who cry depends on proper identification of the cause of crying.
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PMID:A study of crying in medically and surgically hospitalized patients. 356 12

In a study of 60 elderly patients in a general hospital referred for psychiatric assessment, the commonest psychiatric disorders were depressive illness (41.6%) and dementia (35.0%). Patients with depression (mean age 69.5 years) were a younger age group compared with dementia (mean age 75.8 years)--this difference is statistically significant (p less than 0.01). Seven patients with depression were admitted for attempted suicide and 5 were referred because of headache and chest discomfort. The main reasons for referral of patients with dementia were disturbed and confused behaviour. The other psychiatric disorders in the sample were delirium (6.7%), paraphrenia (6.7%), alcohol dependence syndrome (5.0%) and anxiety neurosis (5.0%).
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PMID:Psychiatric referrals of elderly patients in a general hospital. 359 77

The assessment of suicide risk is a central activity of the general hospital psychiatrist for patients admitted following a suicide attempt and others who are identified after admission as being potentially suicidal. While biologic and psychosocial measures have some long-term predictive value, there is no valid measure to predict acute suicide risk. The lack of a valid measure does not, however, relieve the clinician of the obligation to perform an appropriate assessment. Pertinent appellate case law decisions not that the evaluation and record keeping must be "adequate," though no definition for adequate standards is provided. This paper presents issues that are considered so fundamental for suicide assessment that failure to obtain and record such information would potentially constitute inadequate practice. These areas include: the patient's statement regarding current suicidal ideation and planning, the presence or absence of delirium, psychosis and depression, what the patient says it makes sense to do, confirmation by a third party, and global formulation. The guidelines in this paper are presented with the intention of establishing the basis for optimal clinical care and for minimizing legal vulnerability in the evaluation of the potentially suicidal patient in the general hospital.
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PMID:The assessment of suicide risk in the general hospital. 369 51

Inpatient geriatric consultation services have the potential for educating large numbers of health professionals and influencing the clinical care of large numbers of patients. Such consultation can identify new diagnoses and recommend treatment of conditions whose appropriate management can improve patients' functional level. At San Francisco General Hospital, the most frequent recommendations were medication adjustment, management of dementia, delirium or depression, rehabilitation, and treatment of malnutrition. Of 35 patients slated to go to nursing homes at the time of consultation, 18 were rerouted to lower levels of care, and 14 eventually went home. Preliminary findings at the Palo Alto Veterans Administration Medical Center replicate these data.
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PMID:Inpatient geriatric consultation. 381 44

The psychological assessment and management of the critically ill patient is often overlooked as a part of the patient care plan. The intensive care unit (ICU) syndrome is a type of organic brain syndrome manifested by a variety of psychological reactions, including fear, anxiety, depression, hallucinations, and delirium. Causes, treatment modalities, and a multidisciplinary approach to preventing the ICU syndrome are presented. Causative factors that should be assessed in the psychological evaluation of ICU patients include: (1) preadmission history; (2) past ability to adapt to stress; (3) past and current medications; (4) current clinical status; and (5) environmental factors. The treatment of the ICU syndrome includes: (1) the correction or elimination of causative factors; (2) the appropriate choice, dose, and route of administration of anxiolytic and antipsychotic agents; (3) reduction or elimination of sources of environmental stress; and (4) frequent patient and family communication. Finally, the prevention of the ICU syndrome through the involvement of physicians, nurses, and pharmacists is stressed.
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PMID:The intensive care unit syndrome: causes, treatment, and prevention. 388 Dec 34

The authors report a case of encephalitis occurring in a setting consistent with acquired immune deficiency syndrome (AIDS). They point out that AIDS and its complications can mimic psychiatric syndromes, including depression and dementia, or delirium related to illnesses such as alcoholism. Acting out behavior, seen in the present case, may also be mistaken as a symptom of sociopathy.
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PMID:AIDS encephalitis mimicking alcohol dementia and depression. 395 14

The author describes the evaluation and treatment of 67 patients 60 years old or older who were referred to a consultation-liaison service in a university hospital. Age, sex, referring service, reasons for referral, psychiatric diagnosis, and interventions or recommendations were determined. Primary psychiatric diagnoses included depression (24%), dementia (19%), delirium (18%), schizophrenia (16%), and personality disorders (12%). Recommendations or interventions included advice in the use of psychotropic medications (61%), assistance with competency issues (25%), recommendation for further medical evaluation or treatment (36%), individual psychotherapy (28%), family therapy (25%), disposition planning (24%), and transfer to a geropsychiatry unit (12%). Hospitalized elderly patients with emotional problems represent a unique diagnostic and therapeutic challenge.
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PMID:Geropsychiatric consultation in a university hospital: a report on 67 referrals. 397 Feb 70


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