Understanding the expanding role of primary care physicians (PCPs) to primary psychiatric care physicians (PPCPs): enhancing the assessment and treatment of psychiatric conditions

Aim In the current healthcare system primary care physicians (PCPs) have, in effect, become the primary psychiatric care physicians (PPCPs) for many of their patients. Being the PPCP in an already busy and stressful medical industry presents additional time management and treatment challenges to successfully manage patients' medical and psychiatric needs. The aim of the study was to ascertain PCPs' psychiatric assessment and treatment practices and to determine the extent to which PCPs have a need for using a structured psychiatric assessment tool.Method We sent 300 PCPs a survey to examine their psychiatric assessment and treatment practices. A one-page questionnaire was used to inquire about PCPs' psychiatric care practice habits including types of conditions treated, psychiatric medications prescribed, assessment methods used, interest in using a structured assessment tool and referral sources used. Sixty-eight usable surveys (23%) were returned.Results PCPs identify approximately one-third of their patients as mental health patients. They are treating a wide range of psychiatric conditions and prescribing a variety of psychiatric medications. The vast majority are using traditional clinical interviewing as their primary method of psychiatric assessment. However, the majority were willing to use a structured psychiatric assessment tool.Conclusion PCPs are serving a useful role in providing psychiatric treatment to many of their patients. Using a more structured psychiatric assessment method in practice could ultimately strengthen the assessment and treatment of psychiatric conditions in primary care settings.     

Mental health benefits of omega-3 fatty acids may be mediated by improvements in cerebral vascular function

Since the pivotal role of long chain omega-3 (n-3) polyunsaturated fatty acids (PUFA) in brain structure and development became apparent in the 1970s, these lipids have been investigated in relation to a range of psychiatric disorders, with some positive and some conflicting evidence to support their use as a supplementary treatment for various symptoms. A number of mechanisms of action have been proposed to account for their potential benefits, largely based on their structural role in brain development and purported influences on central neurotransmission.Theories on the pathogenesis of mental health and psychiatric illness have traditionally focused on the role of neurotransmitters, although there is also ample evidence that psychiatric disorders are associated with impaired cerebral blood flow (CBF) or impairments in blood-brain barrier (BBB) function. Associations between cardiovascular and psychiatric pathologies are further indicative of a possible underlying vascular component to psychiatric illness. We hypothesise that treatment with vasoactive nutrients that can improve cerebral perfusion may help to improve a variety of mental disorders.In presenting our hypothesis, we provide an overview of cerebral vascular function, focusing specifically on the role of the endothelium in CBF and BBB integrity, and review evidence for associations between impaired CBF/endothelial function and psychiatric illness. Then, as an example of a potential treatment, we review the influence of n-3 PUFA on endothelial function, drawing on evidence of anti-inflammatory, anti-aggregatory and vasodilatory roles in blood flow and vascular permeability. We hypothesise that n-3 PUFA may act on the blood side of the BBB as well as on central neural pathways to influence cerebral functions. In the former case, they may act on endothelial cells to influence both vasodilation and selective permeability, thereby assisting in CBF and delivery of oxygen and glucose to brain tissue in response to requirements.     

Psychiatric Illness in General Practice: A Detailed Study Using a New Method of Case Identification

A self-administered questionary (the General Health Questionnaire) aimed at detecting current psychiatric disturbance was given to 553 consecutive attenders to a general practitioner''s surgery. A sample of 200 of these patients was given an independent assessment of their mental state by a psychiatrist using a standardized psychiatric interview. Over 90% of the patients were correctly classified as “well” or “ill” by the questionary, and the correlation between questionary score and the clinical assessment of severity of disturbance was found to be +0·80.The “conspicuous psychiatric morbidity” of a suburban general practice assessed by a general practitioner who was himself a psychiatrist and validated against independent psychiatric assessment was found to be 20%. “Hidden psychiatric morbidity” was found to account for one-third of all disturbed patients. These patients were similar to patients with “conspicuous illnesses” in terms both of degree of disturbance and the course of their illnesses at six-month follow-up, but were distinguished by their attitude to their illness and by usually presenting a physical symptom to the general practitioner.When 87 patients who had been assessed as psychiatric cases at the index consultation were called back for follow-up six months later, two-thirds of them were functioning in the normal range. Frequency of attendance at the surgery in the six months following index consultation was found to have only a modest relationship to severity of psychiatric disturbance.It is argued that minor affective illnesses and physical complaints often accompany each other and usually have a good prognosis.     

Konsiliardienste in den Fachgebieten „Psychiatrie und Psychotherapie“ und „Psychosomatische Medizin und Psychotherapie“ im Land Sachsen-Anhalt

Objective To assess the availability and the utilization of specialists for psychiatry, psychotherapy and psychosomatic medicine in somatic hospitals in the German state of Sachsen- Anhalt. Method The “Committee for Issues of Psychiatric Care in Sachsen- Anhalt” sent written questionnaires to the medical chairmen of the 46 hospitals with a somatic department; the return rate was 98% with some information about 48 of 55 hospital locations. Results 17 hospitals use specialists from their own clinical facilities (12 from their own psychiatric department for inpatient care and 4 from their own psychiatric day hospital as well as 9 from their own inpatient psychosomatic unit) for psychiatric consultations on somatic wards and were classified as hospitals with “internal” consultation services. 27 hospitals ask for visits from specialists from another psychiatric hospital (14) and/or call colleagues working in private practice (14) and were classified as “external consultation services”, even if they had psychologists among their own staff (3). In another 4 hospitals, no psychiatric services were offered. Only 16 houses had statistical data regarding the frequency of psychiatric consultations at hand; another 22 hospitals provided estimates. The availability of the consultation service was a strong predictor of its utilization: Hospitals with an “internal” service reported about five times more consultations than those hospitals whose consultation services depended on external specialists. Some formal psychotherapeutic qualification was available in nearly all hospitals with internal and in 37% of the hospitals with external services. Conclusions We were able to gather at least some information regarding psychiatric and/or psychosomatic consultation services in about nearly 90% of the local somatic hospitals of the whole state of Sachsen- Anhalt, which is one of the “new” federal states that emerged from the former “German Democratic Republic” and has to catch up to the standards of medical care of the Federal Republic of Germany. The quality of the data, however, left much room for improvement, as only 36% of the hospitals were able to provide the exact number of psychiatric consultations in the previous year or the last six months. The results, nevertheless, suggest considerable deficits in the care of patients with psychiatric disorders especially in those somatic hospitals with no internal psychiatric consultation service. A service “around the clock” was only available in hospitals with a psychiatric inpatient department of their own. We strongly recommend the implementation of regular reports about the utilization of psychiatric consultations in somatic hospitals as an addition to the current measures of quality assurance. Every somatic hospital should have at least one psychiatrist (with some psychotherapeutic training) on its own staff.     

Definitions and diagnoses: Cultural implications of psychiatric help-seeking and psychiatrists' definitions of the situation in psychiatric emergencies

This paper explores lay and psychiatric actors' definitions of mental illness by focusing on several aspects of emergency psychiatric diagnosis. First, it considers psychiatric diagnosis as a social and cultural process in which mental illnesses are defined with increasing specificity as individuals move from lay to psychiatric contexts. Second, the paper considers variation in psychiatric residents' conceptions of mental illness, their role in emergency contexts, and lastly, their diagnostic styles. Diagnostic styles are shown to exist and to be grounded in residents' definitions of the situation. It is suggested that the variation in psychiatrists' definitions of the psychiatric situation, especially as regards etiology, plays a prominent, but as yet unnoted, role in producing variability in psychiatric diagnosis. It is also argued that actors' definitions are cultural, grounded in non-professional. lay ideology, and are not products of secondary professional socialization.     

Psychiatric assessment of patients with “20th-century disease” (“total allergy syndrome”)

“Twentieth-century disease”, or “total allergy syndrome”, is a condition attributed to hypersensitivity to the environment that may sometimes be seen as so serious that the patient is incapable of living in the modern world. Although the popular media frequently carry stories about it, there is little scientific literature. It is diagnosed by clinical ecologists, who maintain, among other theories, that susceptible individuals experience an overload in assaults by artificial materials in the environment. The patients usually have multiple ill defined symptoms for which no organic cause can be found, but they vigorously resist psychiatric referral, as they attribute their symptoms to allergy. A group of 18 patients who were purportedly suffering from 20th-century disease were referred to a university psychiatric consultation liaison service. They virtually all had a long history of visits to physicians, and their symptoms were characteristic of several well known psychiatric disorders. The case histories and management of three of them are presented. Although this group of patients may have been atypical in that they had more severe psychologic symptoms, the experience indicates that a psychiatric diagnosis ought to be considered. The symptoms of 20th-century disease have much in common with other conditions known to physicians for centuries.     

An Emergency Psychiatric Service in a General Hospital

The same extensive range of general hospital facilities should be allocated to emergency psychiatric illness as are available for other medical conditions. During the study herein reported, for every three medical consultations in the emergency ward of a large general hospital, two psychiatric consultations were requested. Over a two-year period when 24-hour coverage by psychiatric consultants was instituted, such assessments increased from 148 to 340 (during the first four months of each year); the increase in police referrals was outstanding, rising from 16 to 105. The general wards of the hospital assumed greater responsibility for further medical treatment, while committal to the mental hospital declined. Many more psychiatric patients could have been treated in the general hospital if facilities had been available. The development of an emergency psychiatric service is not an easy process and co-ordination with other psychiatric resources is required. Residents in training face situations in the emergency ward which are not encountered in any other aspect of their clinical experience.     

Epigenetic regulation in psychiatric disorders

Many neurological and most psychiatric disorders are not due to mutations in a single gene; rather, they involve molecular disturbances entailing multiple genes and signals that control their expression. Recent research has demonstrated that complex 'epigenetic' mechanisms, which regulate gene activity without altering the DNA code, have long-lasting effects within mature neurons. This review summarizes recent evidence for the existence of sustained epigenetic mechanisms of gene regulation in neurons that have been implicated in the regulation of complex behaviour, including abnormalities in several psychiatric disorders such as depression, drug addiction and schizophrenia.     

Psychiatric research: psychoproteomics, degradomics and systems biology

While proteomics has excelled in several disciplines in biology (cancer, injury and aging), neuroscience and psychiatryproteomic studies are still in their infancy. Several proteomic studies have been conducted in different areas of psychiatric disorders, including drug abuse (morphine, alcohol and methamphetamine) and other psychiatric disorders (depression, schizophrenia and psychosis). However, the exact cellular and molecular mechanisms underlying these conditions have not been fully investigated. Thus, one of the primary objectives of this review is to discuss psychoproteomic application in the area of psychiatric disorders, with special focus on substance- and drug-abuse research. In addition, we illustrate the potential role of degradomic utility in the area of psychiatric research and its application in establishing and identifying biomarkers relevant to neurotoxicity as a consequence of drug abuse. Finally, we will discuss the emerging role of systems biology and its current use in the field of neuroscience and its integral role in establishing a comprehensive understanding of specific brain disorders and brain function in general.     

Intermediate phenotypes and genetic mechanisms of psychiatric disorders

Genes are major contributors to many psychiatric diseases, but their mechanisms of action have long seemed elusive. The intermediate phenotype concept represents a strategy for characterizing the neural systems affected by risk gene variants to elucidate quantitative, mechanistic aspects of brain function implicated in psychiatric disease. Using imaging genetics as an example, we illustrate recent advances, challenges and implications of linking genes to structural and functional variation in brain systems related to cognition and emotion.     

The safety of psychotropic drug use during pregnancy: a review

A substantial number of women of childbearing age are prescribed psychotropic drugs, and because nearly 50% of pregnancies are unplanned, many women are still taking them upon becoming pregnant. This article reviews the various classes of psychotropic drugs that are commonly used to treat psychiatric disorders--antidepressants, benzodiazepines, antipsychotics, antiepileptics, lithium and monoamine oxidase (MAO) inhibitors--in terms of their safety during pregnancy. Evidence-based information from epidemiologic studies indicates that most psychotropic drugs are relatively safe for use during pregnancy. There is also an increasingly large body of evidence-based information in the literature indicating that it may be more harmful to both the mother and her baby if she is not treated appropriately when suffering from a severe psychiatric disorder. Therefore, it is important for women with psychiatric disorders and their healthcare providers to have access to evidenced-based information about the safety of these drugs when taken during pregnancy to ensure that women make an informed decision as to whether they should continue with the pharmacotherapy they have been using to treat their condition.     

Psychiatric research: psychoproteomics,degradomics and systems biology

While proteomics has excelled in several disciplines in biology (cancer, injury and aging), neuroscience and psychiatryproteomic studies are still in their infancy. Several proteomic studies have been conducted in different areas of psychiatric disorders, including drug abuse (morphine, alcohol and methamphetamine) and other psychiatric disorders (depression, schizophrenia and psychosis). However, the exact cellular and molecular mechanisms underlying these conditions have not been fully investigated. Thus, one of the primary objectives of this review is to discuss psychoproteomic application in the area of psychiatric disorders, with special focus on substance- and drug-abuse research. In addition, we illustrate the potential role of degradomic utility in the area of psychiatric research and its application in establishing and identifying biomarkers relevant to neurotoxicity as a consequence of drug abuse. Finally, we will discuss the emerging role of systems biology and its current use in the field of neuroscience and its integral role in establishing a comprehensive understanding of specific brain disorders and brain function in general.     

PSYCHIATRIC INPATIENT SERVICES IN GENERAL HOSPITALS

Traditional asylum care of psychiatric patients leads to the isolation, confinement, and restraint of the patients, and to isolation of psychiatric practice from the rest of medicine. Modern psychiatric advances have demonstrated the disadvantages to both patients and their families of such isolation, confinement and restraint. It is in the best interests of patients and professional workers that inpatient psychiatric services be continuous with, and contiguous to, other medical services and to rehabilitation services of all kinds.Examination of currently available information reveals a shortage of psychiatric beds in California, particularly for diagnosis and brief treatment. Thus, not only is there a need to develop psychiatric inpatient facilities, but also an opportunity to develop them along several different lines. Since both the Hill-Burton Act (federal) and the Short-Doyle Act (state) give financial assistance to only those psychiatric services established in general hospitals or affiliated with general hospitals, this requirement calls for examination in the light of experience with services so operated.At first, the Short-Doyle Act was perceived as a panacea for the psychiatric ills of the state. Now it is beginning to be recognized as one method of providing additional mental health resources, rather than the exclusive method. As more short-term cases are treated in local, tax-supported, psychiatric units in general hospitals, an impact can be expected on the state hospital program.In its administration of the Short-Doyle Act, the Department of Mental Hygiene attempts to respond to community needs as locally determined. It tries to insure local option and encourage local responsibility while furthering high standards of staffing and of service.     

Proteomics in the discovery of new therapeutic targets for psychiatric disease

In terms of impact on and cost to society psychiatric disorders are among the most important health problems of today. Current estimates from the US suggest that the collective cost of psychiatric diseases could amount to one-third of the total health care budget with a cumulative lifetime prevalence of 30%. While undoubtedly improvements have been made in the diagnosis and treatment of at least the symptoms of mental illness, there has been frustratingly little progress in elucidating the molecular mechanisms. However, a fundamentally different approach to study molecular mechanisms of psychiatric diseases is emerging as a result of technological advances in expression profiling methods. This comprises the investigation of the expressed disease 'phenotypes', developing from the differential gene and protein expression in the central nervous system as a result of the complex interaction between genetic predisposition and environmental modulation. This paper will focus on proteomics, expression profiling at the protein level, reviewing some of the available tools and their application in the molecular analysis of psychiatric disease.     

Spiritist Psychiatric Hospitals in Brazil: Integration of Conventional Psychiatric Treatment and Spiritual Complementary Therapy

In Brazil, during the XX century, dozens of Spiritist psychiatric hospitals emerged seeking to integrate conventional medical treatment with complementary spiritual therapy. This combined inpatient treatment is largely found in Brazil, where many psychiatric hospitals stem from the Spiritist movement. The present report describes the use of these spiritual practices, their operating structure, health professionals involved, modalities of care, and institutional difficulties in integrating spiritual practices with conventional treatment in six leading Brazilian Spiritist psychiatric hospitals. These hospitals combine conventional psychiatric treatment with voluntary-based spiritual approaches such as laying on of hands (“fluidotherapy”), lectures regarding spiritual and ethical issues, intercessory prayer, spirit release therapy (“disobsession”) and “fraternal dialogue”. The non-indoctrination and optional nature of these spiritual complementary therapies seem to increase acceptance among patients and their family members. In conclusion, the Spiritist psychiatric hospitals in Brazil have, for more than half a century, provided an integrative approach in the treatment of psychiatric disorders, associating conventional and spiritual treatments, more specifically Spiritist therapy. The lack of standardized treatment protocols and scientific studies remain a barrier to assessing the impact of this integrative approach on patients’ mental health, quality of life, adherence, and perceived quality of treatment.     

Indexation of psychiatric journals from low‐ and middle‐income countries: a survey and a case study

There is a marked underepresentation of low- and middle-income countries (LAMIC) in the psychiatric literature, which may reflect an overall low representation of LAMIC publications in databases of indexed journals. This paper investigates the worldwide distribution of indexed psychiatric journals. A survey in both Medline and ISI Web of Science was performed in order to identify journals in the field of psychiatry according to their country of origin. Two hundred and twenty-two indexed psychiatric journals were found. Of these, 213 originated from high-income countries and only nine (4.1%) from middle-income countries. None were found in low-income countries. We also present the experience of a LAMIC psychiatric journal, the Revista Brasileira de Psiquiatria, in its recent indexation process. This case study may serve as an example for other LAMIC journals to pursue indexation in major databases as a strategy to widen the international foundation of psychiatric research. There is an important need for the inclusion of LAMIC psychiatric publications in the major indexation databases. This process will require multiple agents to partner with journals from LAMIC to improve their quality and strengthen their chances of being indexed.     

Intermediate phenotypes in psychiatric disorders

The small effect size of most individual risk factors for psychiatric disorders likely reflects biological heterogeneity and diagnostic imprecision, which has encouraged genetic studies of intermediate biological phenotypes that are closer to the molecular effects of risk genes than are the clinical symptoms. Neuroimaging-based intermediate phenotypes have emerged as particularly promising because they map risk associated gene effects onto physiological processes in brain that are altered in patients and in their healthy relatives. Recent evidence using this approach has elucidated discrete, dissociable biological mechanisms of risk genes at the level of neural circuitries, and their related cognitive functions. This approach may greatly contribute to our understanding of the genetics and pathophysiology of psychiatric disorders.     

Psychological and social evaluation in cases of deliberate self-poisoning admitted to a general hospital.

In a prospective clinical trial 312 cases of self-poisoning (276 patients) consecutively admitted to hospital were randomly allocated to medical teams or to psychiatrists for an initial psychiatric assessment and a decision as to "disposal." Junior doctors and nurses received some instruction in this work. Both groups of assessors asked for help from social workers when necessary. Once the medical teams had completed their assessments, psychiatrists provided most of the hospital treatment. Follow-up at one year showed no significant difference between the two groups of patients in the numbers who repeated their self-poisoning or self-injury (or both), or committed suicide. Provided junior doctors and nurses are taught to assess self-poisoned patients, we think medical teams can evaluate the suicidal risk and identify patients requiring psychiatric treatment or help from social workers, or both. Contrary to the Department of Health''s recommendation that all cases of deliberate self-poisoning should be seen by psychiatrists, we have reached the conclusion that physicians should decide for each of their patients if specialist psychiatric advice is necessary.     

Variability in the Efficacy of Psychopharmaceuticals: Contributions from Pharmacogenomics, Ethnopsychopharmacology, and Psychological and Psychiatric Anthropologies

Psychological and psychiatric anthropology have long questioned the universality of psychiatric diagnoses, bringing to light the fluidity of mental disorder, and recognizing that the experience and expression of psychopathology is influenced by complex and interacting genetic, environmental, and cultural factors. The majority of our discussions, however, have remained centered around the role of culture in shaping mental illness: drawing attention to subjective experiences of mental illness and culturally patterned modes of symptom presentation, and interrogating the cogency of universal diagnostic rubrics. Psychological and psychiatric anthropology have yet to robustly engage the broadly assumed universal validity of psychiatric medications and the ways in which they are prescribed and experienced. This article provides an introduction into the fields of pharmacogenomics and ethnopsychopharmacology, areas of inquiry seeking to understand the ways in which genetic variability occurring between, and within, large population groups influences individual ability to metabolize psychotropic medications. This piece further addresses the complex issue of psychopharmaceutical efficacy, stressing the ways in which, just as with psychopathology, medications and their outcomes are likewise influenced by the complex interactions of genes, environment, and culture. Lastly, ways in which anthropology can and should engage with the growing fields of pharmacogenomics and ethnopsychopharmacology are suggested.     

Ernst Rüdin: Hitler’s Racial Hygiene Mastermind

Ernst Rüdin (1874–1952) was the founder of psychiatric genetics and was also a founder of the German racial hygiene movement. Throughout his long career he played a major role in promoting eugenic ideas and policies in Germany, including helping formulate the 1933 Nazi eugenic sterilization law and other governmental policies directed against the alleged carriers of genetic defects. In the 1940s Rüdin supported the killing of children and mental patients under a Nazi program euphemistically called “Euthanasia.” The authors document these crimes and discuss their implications, and also present translations of two publications Rüdin co-authored in 1938 showing his strong support for Hitler and his policies. The authors also document what they see as revisionist historical accounts by leading psychiatric genetic authors. They outline three categories of contemporary psychiatric genetic accounts of Rüdin and his work: (A) those who write about German psychiatric genetics in the Nazi period, but either fail to mention Rüdin at all, or cast him in a favorable light; (B) those who acknowledge that Rüdin helped promote eugenic sterilization and/or may have worked with the Nazis, but generally paint a positive picture of Rüdin’s research and fail to mention his participation in the “euthanasia” killing program; and (C) those who have written that Rüdin committed and supported unspeakable atrocities. The authors conclude by calling on the leaders of psychiatric genetics to produce a detailed and complete account of their field’s history, including all of the documented crimes committed by Rüdin and his associates.