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12 results

  • Chapter 25 - Mood Disorders: Therapeutic Challenges in the Medically Ill Patient

  • Edited by Allan Young, Institute of Psychiatry, King's College London, Marsal Sanches, Baylor College of Medicine, Texas, Jair C. Soares, McGovern Medical School, The University of Texas, Mario Juruena, King's College London
  • Book:
    Clinical Textbook of Mood Disorders
    Published online:
    16 May 2024
    Print publication:
    23 May 2024, pp 263-276

  • Summary

    Mood disorders are more common in persons with medical illness than in the general population, and add to suffering, morbidity, and mortality. As to diagnosis, emotional states seen in the context of illness range from denial to bland indifference to “normal” sadness, to pathological anxiety and depressive or manic syndromes. Within this range fall both primary mood disorders and mood disorders secondary to the primary illness and its treatment.Treatment is complicated by difficulties with patient engagement and retention, limited clinical trial data, illness-related sensitivity to medications and alterations in drug metabolism, drug side effects, and drug interactions. Limited data are available about potentially valuable treatments such as exercise, transcranial magnetic stimulation, ketamine and psychedelics. Collaborative care models for depression treatment in medical settings are effective but demanding to implement and sustain. Special considerations apply to treatment of patients near the end of life and those requesting hastened death. Psychiatric treatment of the medically ill patient can evoke strong feelings in the treatment provider.

  • Assessment of decisional capacity: Prevalence of medical illness and psychiatric comorbidities

  • Susanne Boettger, Meredith Bergman, Josef Jenewein, Soenke Boettger
  • Journal:
    Palliative & Supportive Care / Volume 13 / Issue 5 / October 2015
    Published online by Cambridge University Press:
    30 October 2014, pp. 1275-1281
  • Objective:

    Studies on decisional capacity have primarily focused on cognitive disorders, whereas noncognitive disorders remain understudied. The purpose of our study was to assess decisional capacity across a wide spectrum of medical and psychiatric disorders.

    Method:

    More than 2,500 consecutive consults were screened for decisional capacity, and 336 consults were reviewed at Bellevue Hospital Center in New York. Sociodemographic and medical variables, medical and psychiatric diagnoses, as well as decisional capacity assessments were recorded and analyzed.

    Results:

    Consults for decisional capacity were most commonly called for in male patients with cognitive and substance abuse disorders. Less commonly, consults were called for patients with mood or psychotic disorders. Overall, about two thirds of patients (64.7%) were deemed not to have decisional capacity. Among medical diagnoses, neurological disorders contributed to decisional incapacity, and among the psychiatric diagnoses, cognitive disorders were most frequently documented in cases lacking decisional capacity (54.1%) and interfered more commonly with decisional capacity than substance abuse or psychotic disorders (37.2 and 25%). In contrast, patients with mood disorders usually retained their decisional capacity (32%). Generally, the primary treatment team's assessment was accurate and was confirmed by the psychiatric service.

    Significance of results:

    Although decisional capacity assessments were most commonly requested for patients with substance abuse and cognitive disorders, the latter generally affected the ability to make healthcare decisions the most. Further, cognitive disorders were much more likely to impair the ability to make appropriate healthcare decisions than substance abuse or psychotic disorders.

  • Prevalenza dei disturbi affettivi (DSM-IIIR) nei pazienti di un reparto di medicina geriatrica. Uno studio epidemiologico con controlli della popolazione generale

  • Cesare Turrina, Maria Steinmayr, Orazio Piasere, Orazio Siciliani
  • Journal:
    Epidemiologia e Psichiatria Sociale / Volume 2 / Issue 1 / April 1993
    Published online by Cambridge University Press:
    07 August 2014, pp. 47-52

  • Objective - To investigate the rate of DSM-IIIR main affective disorders in a sample (52) of elderly medical patients consecutively admitted to a geriatric ward; to look for risk factors associated with depression; to compare the rate of depression with the one detected in community controls (117 subjects). Design - All consecutive patients admitted during January-February 1990 were assessed with a standardized psychiatric interview (Geriatric Mental State Examination) and with the Mini-Mental State Examination. Setting - The IV Geriatric Division (ward and day-hospital), Ospedale Civile Maggiore of Verona, which cares for elderly affected by medical illnesses. Main outcome measures - Depression was diagnosed according to the main DSM-IIIR categories for mood disorders. Results - Overall, an affective disorder was diagnose in 25% of the subjects (major depression 5,7%, dysthymic disorder 3,8%, n.o.s. depression 13,4%, adjustment disorder with depressive mood 1,9%). This rate was significantly higher when compared with the prevalence detected in community controls (25% vs. 11,1%). Older age, female sex, physical disability and distressing events were not associated with affective illness, while the lack of social support was significantly associated with depression. Conclusions - Elderly medical patients turned out to be an high risk group for depression, which deserves psychiatric screening and specific treatment.

  • Demoralization: a systematic review on its clinical characterization

  • L. Tecuta, E. Tomba, S. Grandi, G. A. Fava
  • Journal:
    Psychological Medicine / Volume 45 / Issue 4 / March 2015
    Published online by Cambridge University Press:
    17 July 2014, pp. 673-691
  • Background

    Demoralization has been described as a psychological state characterized by helplessness, hopelessness, a sense of failure and the inability to cope.

    Methods

    We conducted a systematic review with qualitative data analysis following PRISMA criteria with the following aims: to review validated assessment instruments of the demoralization syndrome, report main findings regarding demoralization as measured by validated instruments that emerge in the literature, compare and report evidence for the clinical utility of the identified instruments. Utilizing the key word ‘demoralization’ in PubMed and PsycINFO databases, an electronic search was performed, supplemented by Web of Science and manual searches. Study selection criteria included the assessment of medical patients and use of instruments validated to assess demoralization. Seventy-four studies were selected.

    Results

    Four instruments emerged in the literature. Main findings concern prevalence rates of demoralization, evidence of discriminant validity from major depression, factors associated with demoralization and evidence of clinical utility. The instruments vary in their definition, the populations they aim to assess, prevalence rates they estimate and their ability to discriminate between different conditions. Nonetheless, demoralization appears to be a distinctive psychological state characterized by helplessness, hopelessness, giving up and subjective incompetence. It is not limited to life-threatening diseases such as cancer, but may occur in any type of clinical situation. It is associated with stress and adverse health outcomes.

    Conclusions

    Studies addressing the incremental value of demoralization in psychiatry and psychology are needed. However, demoralization appears to entail specific clinical features and may be a distinct condition from major depression.

  • 22 - The psychodynamic treatment of mood disorders

  • from Section 3 - Psychotherapies for mood disorders
  • Edited by J. John Mann, Columbia University, New York
  • Edited in association with Patrick J. McGrath, Columbia University, New York, Steven P. Roose, Columbia University, New York
  • Book:
    Clinical Handbook for the Management of Mood Disorders
    Published online:
    05 May 2013
    Print publication:
    09 May 2013, pp 289-298

  • Summary

    Depression secondary to medical illness is an appropriate diagnosis when the physiological effects of the illness on the brain directly result in depressive symptoms. Several medical disorders are associated with depressive symptoms in this way. Occult hypothyroidism exemplifies disorders in which recognition and treatment of the underlying condition may alleviate depression symptoms. In addition to organic causes of depression in the medically ill, other relevant factors to consider and explore with patients include: the meaning of the illness to the patient, the patient's causal attributions about illness, distorted cognitions or maladaptive behavioral responses to illness, coping mechanisms, and strengths or weaknesses which may be imbedded in patients' premorbid personality traits and style. When rapid improvement of depressive symptoms is the goal, psychostimulants have been useful in patients with advanced cancer. The suggestion that antidepressants increase the risk of cancer has been refuted.

  • Chapter 24 - Restraint and seclusion techniques in the emergency department

  • from Section 4. - Treatment of the psychiatric patient
  • Edited by Leslie S. Zun
  • Edited in association with Lara G. Chepenik, Mary Nan S. Mallory
  • Book:
    Behavioral Emergencies for the Emergency Physician
    Published online:
    05 April 2013
    Print publication:
    21 March 2013, pp 177-181

  • Summary

    It is given that medical illness is common in psychiatric patients and that psychiatric pathology is common in medical conditions. Within the emergency department, psychiatric patients make-up one of the major diagnostic categories. Evaluation of pre-existing and comorbid psychiatric conditions and their treatments, which can have a profound impact on the patient's medical evaluation, differential diagnosis, and treatment plan, should quickly follow stabilization of the emergency condition. According to the NIMH Epidemiologic Catchment Area Program, more than half of those that abuse drugs have a psychiatric comorbidity with an odds ratio of 4.5. Polypharmacy is a growing national problem, not just in the comorbid medical-psychiatric patient, and is noted especially in select patient populations like nursing homes, a growing referral source for many emergency departments. Psychiatric patients are often taking adjunctive medications such as tricyclic antidepressants, anticonvulsants, and benzodiazepines that can be adjusted to serve dual therapeutic purpose.

  • Chapter 10 - Agitation in patients with dementia

  • Edited by James J. Amos, University of Iowa, Robert G. Robinson, University of Iowa
  • Book:
    Psychosomatic Medicine
    Published online:
    04 August 2010
    Print publication:
    27 May 2010, pp 89-99

  • Summary

    It is important to remember that medical illness and hospitalization can be very stressful, even for the most well adjusted individuals. Under stressful situations, individuals may regress and display personality styles inconsistent with their typical behavior, or may display extremes of typical behavior. Classically, coping has been defined as how an individual manages and attempts to alter a stressful situation. Whereas coping styles are primarily consciously applied behavioral actions, defense mechanisms are largely unconscious, psychological processes used by patients to deal with reality and to maintain self-image. Classically, countertransference was explained as reactions to a patient that represent the past life experiences of the clinician. Although it is not obvious, passive aggression and idealization are very common in dependent clingers. Despite limited evidence for the use of psychotropic medications in personality disorders, they still can have some benefit.

  • A survey of old age psychiatry consultation/liaison services in Ireland

  • Julianne Reidy, Michael Kirby
  • Journal:
    Irish Journal of Psychological Medicine / Volume 25 / Issue 2 / June 2008
    Published online by Cambridge University Press:
    13 June 2014, pp. 66-68
    Print publication:
    June 2008

  • Objectives: The aim of this survey was to assess current structures for provision of consultation/liaison services to older people in the Republic of Ireland, and to ascertain the proportion of referrals to psychiatry of old age arising from consultation/liaison referrals.

    Methods: A postal questionnaire was sent to the 19 public sector, old age psychiatry services, operating in 2005. Information was obtained from 15 of these 19 services regarding the referrals they received in 2005.

    Findings: Consultation/liaison referrals make up 36% of total referrals to psychiatry of old age services. Two of 14 services had ring-fenced resources for consultation/liaison work. Three of 14 consultants described their service as having a significant liaison component. Location of the service and the criteria for accepting a referral are associated with the proportion of referrals that are consultation/liaison.

    Conclusions: Consultation/liaison referrals make up a significant proportion of referrals. To provide an effective consultation/liaison service ring-fenced resources are required. Despite this recent long term strategies for national service development have neglected this area.

  • 12 - Medical issues regarding incarcerated adolescents

  • Edited by Carol L. Kessler, Columbia University, New York, Louis James Kraus, Rush University, Chicago
  • Book:
    The Mental Health Needs of Young Offenders
    Published online:
    11 August 2009
    Print publication:
    06 September 2007, pp 255-269

  • Summary

    Incarcerated teens are at risk for a wide variety of injuries and illnesses. Careful screening and follow-up assures the teen will medically benefit from incarceration and improve their chances of rehabilitation. This chapter is divided into four sections: medical problems that may predispose to delinquent behavior; medical illness and injury likely to result from delinquent behavior; health concerns for all adolescents; and health maintenance issues. Governmental agencies advocate for appropriate research and have built-in safeguards for all research involving prisoners, including stipulating the types of permissible research. Medical personnel at large facilities should be involved as primary investigators or as collaborators with other investigators. Conducting sound ethical, targeted research will greatly aid progress in reducing the burden of crime and illnesses for juvenile delinquents. Cooperation is necessary among medical, custody, and judicial personnel to obtain funding for studies and to facilitate the conduct of research.

  • Old age medical patients screening positive for depression

  • Adrian Mark Winrow, John David Holmes
  • Journal:
    Irish Journal of Psychological Medicine / Volume 22 / Issue 4 / December 2005
    Published online by Cambridge University Press:
    13 June 2014, pp. 124-127
    Print publication:
    December 2005

  • Objective: The aim was to observe whether medical inpatients screening positive for depression using the Geriatric Depression Scale (GDS) continue to screen positive following hospital discharge.

    Method: Participants aged 65 or over, were recruited from consecutive admissions to a city teaching hospital. Subjects had an Abbreviated Mental Test Score (AMTS) of seven or above and a GDS-15 score of five or above. Information was collected on past psychiatric history and living arrangements. Subjects were followed-up three months later and the GDS repeated.

    Results: Thirty subjects were recruited and 26 (87%) followed-up. Ten (38%) no longer scored positive on the GDS, and overall the mean GDS score decreased by two points (Z = 2.235 p < 0.05). Patients with a past psychiatric history or living alone were more likely to be depressed at follow-up. No participants were referred to the psychiatric service or started on antidepressant medication during the course of the study.

    Conclusion: Depressive symptoms are likely to persist following hospital discharge, especially in those patients with a past psychiatric history. An understanding of the risk factors associated with persistent depressive symptoms is necessary if the patients appropriate for treatment are to be identified.

  • Screening for depression in hospitalised elderly medical patients

  • Barbara Farragher, Margo Wrigley, Orla Donohoe, Joseph Duggan
  • Journal:
    Irish Journal of Psychological Medicine / Volume 13 / Issue 4 / December 1996
    Published online by Cambridge University Press:
    13 June 2014, pp. 144-147
    Print publication:
    December 1996

  • Objective: The aim of this study was to screen a group of medically ill elderly hospitalised patients for depression and to facilitate this using a new screening questionnaire called the Evans Liverpool Depression Rating Scale (ELDRS).

    Method: The questionnaire was administered by a geriatric registrar to a consecutive series of 37 acutely ill elderly medical inpatients admitted to an acute hospital ward. They were subsequently interviewed by a member of the psychiatry of old age team.

    Results: Seven of the 37 acutely ill elderly patients admitted to hospital were found to be suffering from a major depressive illness according to DSMIIIR criteria. Of the patients screened, two were already on antidepressant medication. Five of the depressed patients were identified by using the ELDRS. All of the depressed group were judged to require antidepressant medication and two were referred to a psychiatry of old age day hospital.

    Conclusions: Our results suggest that there is a raised prevalence of depressive illness in elderly acutely ill medical patients which remains undetected. Use of a screening questionnaire such as the ELDRS would increase the likelihood of its identification in this group.