THE PRACTICING PHYSICIAN AND MENTAL HEALTH

Neuropsychiatric disabilities are the number one problem in medicine. More specialists are needed in the field of neuropsychiatry. Better psychiatric orientation of nonpsychiatric physicians is needed and there must be infinitely more research into psychiatric problems. We need more adequately equipped and staffed hospitals, both private and public, to care for the problem, and an alerted public as well as a sympathetic, understanding medical profession.     

SUICIDE PROBLEMS IN MEDICAL PRACTICE

Increasing awareness by physicians in general medical practice of the possibility of suicide in nonpsychiatric patients is indispensable for the evaluation of suicide risk and for a practical approach to the problem of prevention.An analysis was made of the records of 11 cases of suicide by medical and surgical patients who were in a general nonpsychiatric Veterans Administration hospital for evaluation and treatment of physical disease.It was noted that the general hospital staff had a low index of suspicion of the possibility of suicide in general hospital patients.It appeared from this study that there is a definite suicide risk in older persons hospitalized for physical illness who develop psychotic reactions during the course of their illness and hospitalization. The signs and symptoms of toxic and organic psychosis in these older patients were not recognized and their significance relative to suicide risk was not appreciated. Although psychiatric signs of severe emotional disturbance appeared clinically obvious at least 24 hours before suicide in ten of the eleven patients, no suicide risk was considered present, nor were adequate precautions taken by the hospital staff. This was owing to the lack of psychiatric orientation among the nonpsychiatric physicians.     

Psychiatric illness in the medical profession: incidence in relation to sex and field of practice.

The overall incidence of psychiatric illness among the physicians of British Columbia during 1970-74 was 1.27% per year. The overall suicide rate was more than 36.5/100 000. Incidence was not dependent on sex or age. The two specialties with the highest incidence--ophthalmology and psychiatry--had previously been demonstrated to have significantly high rates of suicide. The highest incidence was among psychiatric residents; in other resident groups collectively the incidence was at the expected rate. Greater severity of illness and poorer prognosis was found in family physicians compared with specialists, although the incidence was the same in the two groups.     

Why psychiatric conditions are special: an evolutionary and cross-cultural perspective

In non-Western and premodern societies, approaches to sickness involved moral considerations laden with existential and spiritual implications. Healers and physicians had access to this aspect of their patient's lives, were expected to use it constructively, and often did so. The contemporary biomedical theory of disease no longer assigns to illness such metaphysical connotations. While general physicians are permitted - perhaps even advised - to avoid involvement in morally laden dialogues tied to illness and the self, such dilemmas are more prominent and qualitatively different in psychiatry, as psychiatric conditions often entail changes in self-conception, psychological disaffection, unacceptable behavior, and untoward personal reactions to social circumstances. Manifestations of psychiatric conditions can overwhelm an individual's control in areas of cognition, emotion, autonomy, social responsibility, behavior, and body functions - exactly those matters that "modern" individualistic minds are supposed to master. Consequently, psychiatric conditions challenge basic presuppositions of the modern, secular credo about personhood, disease, and behavior. They comprise a species of human problems ontologically distinct from the conditions handled by other medical disciplines.     

Psychiatric Morbidity and Referral on Two General Medical Wards

Psychiatric morbidity among 230 medical inpatients was determined by a two-stage screening procedure, using the General Health Questionnaire and Standardized Psychiatric Interview. Of these patients, 23% were considered psychiatrically ill, affective disorders being the commonest illnesses encountered; and 27 (12%) were psychiatrically referred. While referral was related to severity of psychiatric illness and previous psychiatric illness, the degree to which the psychiatric illness obtruded or created problems in management appeared more crucial in determining referral. In half of those with psychiatric illness the problems did not appear to have been detected or dealt with. It is suggested that medical clerking should routinely include questions about mood and psychological responses to illness.     

Prevention of Mental Disorder—The Role of the General Practitioner

As prevention in psychiatry really refers to early detection and consequent prevention of complications and chronicity, the general practitioner is the most important person in the medical community in preventing mental disorders. As more postgraduate courses in psychiatry become available to practicing family physicians, the majority of patients with psychiatric disorders will be effectively managed by the general medical practitioner.The family physician is already doing this, although not as well as he could. In some instances, he may be unaware of the extent to which the disease with which he deals is psychic disease. As the number of community health centers increases, family physicians will play a vital role in their function. With the necessary knowledge to detect psychic disturbance and to treat emotional disorders effectively, the family physician will prevent many of the instances of progression to chronic psychiatric illness with which we are now plagued. The psychiatrist of the future will act as consultant, treating only patients with the more complicated mental disorders.     

Neurasthenia as nosological dilemma

While researching concepts of neurasthenia as described by patients and physicians of various backgrounds, it was found that there is a great discrepancy between the two groups. In this study, questionnaires were administered to 70 psychiatric patients, 6 Chinese medicine men, 44 general physicians and 35 neuropsychiatrists, to inquire into the reasons for positive or negative attitudes toward neurasthenia. Half of the clinical patients believed that they were suffering from neurasthenia. Neurasthenia is a predominate term used for various types of distress arising mainly from psychiatric diseases. Chinese medicine men are aware that this term is a medical diagnosis introduced from the West. Through experience they regard neurasthenia as a kind of deficit of nerve. Apparently, the concept of neurasthenia has been integrated into the Chinese medical system, a fact substantiated by its longstanding, nosological use by the public.Younger generation physicians within both general and neuropsychiatric disciplines on the whole reject neurasthenia as a diagnostic term. However, one-third of neuropsychiatrists and 40% of general physicians use this term in their practice in order to improve the treatment of and to establish good communication and rapport with the patients whom they treat. Most of them, however, do not use the term in their formal diagnosis. The concept of the illness, neurasthenia, is historically rooted and today presents a nosological dilemma. It will eventually be transformed conceptually and disappear from the public mind.     

Advances in Multiphasic Screening and Testing

The multiphasic testing center of the future will probably be used both for periodic screening tests and for referrals by practicing physicians. Recent widespread interest of several branches of the Federal Government in multiphasic screening stems from the possibility that, through its use, the enormous cost of chronic illness to the country may be reduced.Recent advances in automation and the storage, retrieval, and analysis of data by computers make it economically feasible to obtain much more information about the patient''s health than ever before. New instrument developments include both screening and diagnostic analysis of electrocardiograms by computers, analysis of heart sounds by computer, and a wide variety of other physiological and biochemical instruments.To allow for the inclusion and evaluation of these new procedures, a number of multiphasic testing centers will be needed which can do both research and routine testing. Close cooperation between the medical profession, the public health services and industry will be needed to best serve both the public and the medical profession.     

Laboratory technicians; the Clinical Laboratory Law and its meaning to private physicians

The present laws and regulations relating to clinical laboratories in California are the outcome of over a quarter century of cooperative development. The medical profession, public health department, laboratory workers, and the legislature have worked together in this development.At first the system of certifying technicians and laboratories was on a voluntary basis. The clinical laboratory law in effect legalized and made generally applicable a system which had already been accepted voluntarily. The application of the clinical laboratory law provides physicians a reasonable assurance that competence and reliability will prevail in clinical laboratory operation. Of great importance is the conduct of proper training programs by approved laboratories. Since modern medical practice is so dependent on accurate clinical laboratory work it is essential that special effort be directed by physicians toward influencing young people to enter the profession of medical technology.     

Poverty in the United States as Defined by Federal Standards—Report of the Bureau of Research and Planning

The subject of this Socio-Economic Report is of tremendous importance to the medical profession because physicians should be aware that future programs for the expansion of health care services will be based and, in fact, are being based upon information which this Report contains. The relationship between poverty and accessibility of health care services is therefore quite direct. So, too, will be the impact upon the profession and the organization of medical practice.The 1966 amendments to the Poverty Act are concerned with neighborhood health centers and a vast array of other programs which will touch every physician and every community which can be identified by the standards indicated in this Report as low income, poor, or near poor. For this reason the California Medical Association Committee on Welfare Medical Programs, among several others concerned with aspects of this problem, is trying to alert every county medical society of developments as well as of the responsibilities they should assume in working with the Office of Economic Opportunity and other community organizations in providing guidance and leadership in structuring programs compatible with the interests of the public and the health care professions.This Report on poverty presents a current and prospective view of the problems and issues to be faced. Unless physicians see the relationship and join in a community effort to aid in resolving an issue which underlies public policy, we shall be looking back five or ten years from now to point out that we failed to take advantage of opportunities to assist in the development of a rational system of medical care for low-income groups.Individual physicians, component medical societies on a grass-roots level and CMA as a state organization should all be concerned with and aware of the facts.     

Explanatory Models and Mental Health Treatment: Is Vodou an Obstacle to Psychiatric Treatment in Rural Haiti?

Vodou as an explanatory framework for illness has been considered an impediment to biomedical psychiatric treatment in rural Haiti by some scholars and Haitian professionals. According to this perspective, attribution of mental illness to supernatural possession drives individuals to seek care from houngan-s (Vodou priests) and other folk practitioners, rather than physicians, psychologists, or psychiatrists. This study investigates whether explanatory models of mental illness invoking supernatural causation result in care-seeking from folk practitioners and resistance to biomedical treatment. The study comprised 31 semi-structured interviews with community leaders, traditional healers, religious leaders, and biomedical providers, 10 focus group discussions with community members, community health workers, health promoters, community leaders, and church members; and four in-depth case studies of individuals exhibiting mental illness symptoms conducted in Haiti's Central Plateau. Respondents invoked multiple explanatory models for mental illness and expressed willingness to receive treatment from both traditional and biomedical practitioners. Folk practitioners expressed a desire to collaborate with biomedical providers and often referred patients to hospitals. At the same time, respondents perceived the biomedical system as largely ineffective for treating mental health problems. Explanatory models rooted in Vodou ethnopsychology were not primary barriers to pursuing psychiatric treatment. Rather, structural factors including scarcity of treatment resources and lack of psychiatric training among health practitioners created the greatest impediments to biomedical care for mental health concerns in rural Haiti.     

The clinical psychologist; his role in private medical practice

The independent diagnosis and treatment of mental and nervous disorders according to California law constitutes practicing medicine. By this yardstick, an increasing number of clinical psychologists are entering the private practice of medicine. The medical profession has not provided through its leadership the opportunity for clinical psychologists to utilize their skills in a legitimate and supervised way in the treatment of private patients, nor has the medical profession taken sufficient interest in modern methods of treating patients with psychogenic disorders. If the psychiatric team is a feasible and practical approach to spreading the base of psychiatric treatment in hospitals and clinics, it should be applicable to private practice settings too. In the team setting, the psychologist can render great assistance to the physician in the diagnosis and treatment of patients with psychogenic disorders without compromising the principle that the primary responsibility for the patient is the physician's. By virtue of his training and experience, it is the psychiatrist who is best qualified to supervise the work of the psychologist; and until such time as the medical profession is better acquainted with psychotherapeutic techniques, the employment of psychologist assistants should be (according to good medical practice) left to the psychiatrist. The need for some regulation of the use of the title "psychologist" is increasing in order to protect the public from quacks who pose as psychologists. However, any law which is directed toward elimination of the quack should specifically define psychotherapy and contain provisions for its use under adequate medical supervision. The medical profession is obligated to take its traditional role in providing the best possible treatment for patients who are in need of it, and psychotherapy is an inherent part of treatment.     

Définition du seuil de la pathologie nommée “dysfonctions érectiles”. Où commence l’insuffisance érectile?

“Erectile dysfunction” is a poor term and should be replaced by “erectile insufficiency”, as although everybody knows the function of erections obtained in response to sexual excitation, the role of nocturnal erections (about 95% of erection time) is unknown. Although erectile insufficiency is generally experienced as a cruel handicap, it may not justify the status of a disease. It is also questionable to make it a psychiatric illness. Finally, erection and sexuality in general, should not be confined within certain norms, even when these norms are defined by the medical profession. However, the physician is faced with all these problems presented by this normal man who consults for impotence at a time when drugs are now available on the market, which are able to induce or facilitate erection (this latter group was previously called aphrodisiacs).     

The nature of psychiatric disorders

A foundational question for the discipline of psychiatry is the nature of psychiatric disorders. What kinds of things are they? In this paper, I review and critique three major relevant theories: realism, pragmatism and constructivism. Realism assumes that the content of science is real and independent of human activities. I distinguish two “flavors” of realism: chemistry‐based, for which the paradigmatic example is elements of the periodic table, and biology‐based, for which the paradigm is species. The latter is a much better fit for psychiatry. Pragmatism articulates a sensible approach to psychiatric disorders just seeking categories that perform well in the world. But it makes no claim about the reality of those disorders. This is problematic, because we have a duty to advocate for our profession and our patients against other physicians who never doubt the reality of the disorders they treat. Constructivism has been associated with anti‐psychiatry activists, but we should admit that social forces play a role in the creation of our diagnoses, as they do in many sciences. However, truly socially constructed psychiatric disorders are rare. I then describe powerful arguments against a realist theory of psychiatric disorders. Because so many prior psychiatric diagnoses have been proposed and then abandoned, can we really claim that our current nosologies have it right? Much of our current nosology arose from a series of historical figures and events which could have gone differently. If we re‐run the tape of history over and over again, the DSM and ICD would not likely have the same categories on every iteration. Therefore, we should argue more confidently for the reality of broader constructs of psychiatric illness rather than our current diagnostic categories, which remain tentative. Finally, instead of thinking that our disorders are true because they correspond to clear entities in the world, we should consider a coherence theory of truth by which disorders become more true when they fit better into what else we know about the world. In our ongoing project to study and justify the nature of psychiatric disorders, we ought to be broadly pragmatic but not lose sight of an underlying commitment, despite the associated difficulties, to the reality of psychiatric illness.     

Automatic speech recognition — Can it improve the man-machine interface in medical expert systems?

Computer-aided medical diagnosis has existed for two decades, but has not yet attained widespread acceptance among physicians. It is proposed that automatic speech recognition may be a significant factor in the eventual acceptance of the technology by the medical profession. The current state-of-the-art of automatic speech recognition is briefly surveyed, and problems with the technology are discussed. A potential natural language interface with DIAG, an expert system for aiding in dermatologic diagnosis, is described. A system that has been developed for accepting input of body parts in freestyle format is presented as a prototype for a natural language interface with an automatic speech recognition device.     

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.     

Detecting anxiety and depression in general medical settings.

To aid general practitioners and other non-psychiatrists in the better recognition of mental illness short scales measuring anxiety and depression were derived by latent trait analysis from a standardised psychiatric research interview. Designed to be used by non-psychiatrists, they provide dimensional measures of the severity of each disorder. The full set of nine questions need to be administered only if there are positive answers to the first four. When assessed against the full set of 60 questions contained in the psychiatric assessment schedule they had a specificity of 91% and a sensitivity of 86%. The scales would be used by non-psychiatrists in clinical investigations and possibly also by medical students to familiarise them with the common forms of psychiatric illness, which are often unrecognised in general medical settings.     

Hospitalization for mental illness: evaluation of admission trends from 1941 to 1971.

A study of the diagnostic composition of the inpatient population of Ontario and Canadian psychiatric facilities has shown an important change in hospital-treated illness over the period 1941-71. Patients with nonpsychotic disorders accounted for 54% of all admissions to Ontario public mental hospitals in 1971, compared with only 8% in 1941. The trend was similar for both first admissions and proportion of readmissions, and was similar for psychiatric units of general hospitals. In contrast, the overall rate of first admission for psychotic disorders to inpatient facilities remained remarkably constant over time, as did the proportion of readmissions among all admissions. The findings dispel the notion that the increasing proportion of readmissions is due largely to a rapid turnover of former long-stay psychotic patients (the "revolving-door phenomenon"). The findings could not be attributed to a changing prevalence of types of psychiatric illness, increased availability of psychiatric inpatient facilities or comprehensive medical insurance.