BACKGROUND: Patients with serious mental illness (SMI; e.g., psychotic disorders and major mood disorders) die earlier, have more medical illnesses, and receive worse medical care than those in the general population. OBJECTIVE: The aims of this article are to review the data on medical morbidity and mortality in those with SMI, to highlight the factors that lead to such disparities, and to discuss potential solutions to the problem. METHOD: The authors reviewed the literature on medical morbidity and mortality in those with SMI. RESULTS: Adults with SMI in the United States die 25 years earlier than those in the general population; cardiovascular disease is responsible for the majority of this excess mortality, accounting for roughly 50%–60% of the deaths due to medical illness. Patient, provider, and system-level factors interact to contribute to poor health outcomes in people with SMI. CONCLUSION: Patients with SMI are losing many years of life to preventable and treatable medical illnesses. Solutions to the problem will require attention to patient, provider, and system-level factors.

BACKGROUND: Adjuvant IFN- treatment for patients with malignant melanoma is often complicated by depression. The influence of dosage, however, is unknown. OBJECTIVE: The authors sought to elucidate this dosage effect. METHOD: Using the Zung Self-Rating Depression Scale and the German Bf-S Self-Rating (Affectivity) Scale, the authors prospectively compared the frequency and severity of IFN-–induced depressive symptoms between a group of 29 patients receiving low-dose and 17 patients getting high-dose induction therapy for 4 weeks. RESULTS: Patients receiving high-dose induction treatment had significantly higher depression scores after 4 weeks, and significantly more patients in the high-dose group developed depression. CONCLUSION: The authors concluded that frequency and severity of IFN-–associated depression during melanoma treatment are dose-dependent.

BACKGROUND: Parkinson’s disease (PD) affects patients’ lives with more than just physical impairment. Many of the non-motor aspects of PD, such as cognitive impairment, depression, and sleep disturbances, are common and are associated with a variety of poor outcomes. However, at present, the pathophysiology and clinical management of these symptoms are poorly understood. OBJECTIVE: The authors sought to determine the associations between various illness-associated cytokines, cortisol, and the non-motor symptoms of PD. METHOD: The authors examined a panel of cytokines (IL-1β, IL-6, IL-10, TNF-) and cortisol in a cohort of 52 PD patients with depression. RESULTS: There were a number of significant correlations between the non-motor symptoms and TNF-. Specifically, the authors found that TNF- (but not IL-1β, IL-6, IL-10, or cortisol) was significantly correlated with measures of cognition, depression, and disability. In regression analyses accounting for all variables, TNF- was consistently significant in explaining variance in cognition, depression, sleep, and disability. CONCLUSION: These data are consistent with a growing body of literature that implicates inflammatory cytokines in neural and behavioral processes and further suggests that TNF- may be involved in the production and/or maintenance of non-motor symptoms in PD.

BACKGROUND: Only sparse evidence from controlled clinical trials is available to guide the psychiatric treatment of persons with HIV/AIDS. OBJECTIVE: The authors assessed and determined current treatment trends in AIDS psychiatry. METHOD: Members of the Organization of AIDS Psychiatry (OAP) participated in a web-based survey. RESULTS: Of 159 members, 62 (39%) responded to the survey. Consensus emerged regarding first-line treatment for depression (escitalopram/citalopram), for psychosis and secondary mania (quetiapine), and for anxiety (clonazepam). CONCLUSION: Consensus statements can serve as a preliminary step toward providing some standardization of care for persons with HIV/AIDS.

BACKGROUND: Fibromyalgia, as defined by the American College of Rheumatology, is characterized by widespread pain lasting for at least 3 months, with pain in at least 11 out of 18 tender points when palpated with digital pressure. OBJECTIVE: The authors investigated the relationship between changes in pain and symptoms of anxiety and depression, using data from pregabalin clinical trials. METHOD: Results from three double-blind, placebo-controlled trials of pregabalin monotherapy in fibromyalgia (8–14 weeks) were pooled, and baseline to end-point changes in pain and Hospital Anxiety and Depression Scale (HADS) scores were analyzed. Path-analysis evaluated the association between improvements in anxiety and depression and pain relief. RESULTS: Baseline HADS scores indicated moderate-to-severe anxiety in 38% of patients and moderate-to-severe depressive symptoms in 27%. The improvement in pain was not related to baseline levels of anxiety or depression. The correlation between changes in pain and depressive or anxiety symptoms was low-to-moderate. Path-analysis showed that most of the pain relief observed with pregabalin treatment was a direct analgesic effect and was not explained by improvement in mood. CONCLUSION: Response to treatment of pain in the pregabalin trials did not depend on baseline levels of anxiety or depressive symptoms, and pregabalin improved pain in fibromyalgia patients with or without depressive or anxiety symptoms. Changes in the level of anxiety or depression had a low-to-moderate impact on pain reduction. Pain reduction with pregabalin treatment appeared to result mostly from a direct treatment effect, rather than an indirect effect mediated through improvement in anxiety or depressive symptoms.

BACKGROUND: Medical comorbidity and mortality disproportionately affect adults with serious mental illness, as compared with the general population. OBJECTIVE: This study examined the medical diagnoses of patients transferred from a psychiatric health facility to general-medical hospitals. METHOD: The authors retrospectively reviewed the charts of 81 adult patients admitted to an inpatient psychiatric facility who were subsequently transferred to local general-medical hospitals from January 2005 to June 2007. RESULTS: Of 6,688 separate inpatient admissions, 81 patients (2.1%) were admitted to general-medical hospitals a total of 93 times, and had 108 admitting medical diagnoses. The leading admission indications were infections (N=33; 34%), electrolyte or nutritional abnormalities (N=12; 11%), and cardiovascular disorders (N=12; 11%). Iatrogenic causes related to psychiatric medications accounted for a small proportion of medical admissions (N=8; 7.5%). Over 90% of the patients had chronic medical disorders, and 80% of the patients had a psychotic or bipolar disorder. CONCLUSION: Patients with severe mental illness and chronic medical disorders may experience significant acute medical complications during inpatient psychiatric treatment. Given the complex care issues involved, continued vigilance in treating or preventing these conditions is warranted.

BACKGROUND: Soldiers often return from war with a variety of combat-related mental health conditions, including posttraumatic stress disorder, depression, and substance-use disorders. OBJECTIVE: The authors investigated common co-occurring medical and psychiatric conditions and patterns of conditions among returning Iraq/Afghanistan veterans using the Veterans Administration (VA) healthcare systems. METHOD: Common clusters of ICD–9 diagnostic-related conditions among returning soldiers (N=293,861) were extracted from the VA data center. RESULTS: Diagnoses involving pain are extremely common among returning veterans seeking health care at the VA. In addition to pain-related conditions, psychiatric disorders rank second most prevalent. Psychiatric disorders, and in particular the multimorbid triad of pain, posttraumatic stress disorder, and depression frequently overlap. CONCLUSION: As more veterans return from war, there will be greater need for effective services. Given the findings of high rates of comorbidity and multimorbidity, VA services should be reorganized so as to co-locate psychiatric staff in pain centers, simultaneously targeting pain and psychiatric disorders.

BACKGROUND: Neurological and psychiatric manifestations of systemic lupus erythematosus (SLE) are prevalent in children with SLE. There are few data on the evaluation and management of psychotic features in children with this systemic autoimmune disorder. OBJECTIVE: The authors describe contemporary Child and Adolescent Psychiatry Consultation and Liaison service management of acute psychosis in children with lupus. METHOD: The authors reviewed the records (2003–2008) of all pediatric SLE inpatients who were administered a traditional or atypical antipsychotic agent. They describe clinical features, initial and discharge mental status examinations, and inpatient psychotropic medication usage. RESULTS: Ten pediatric SLE patients (age 10–19 years) required psychiatric management for psychosis during the review period. Paranoid delusions (70%), visual hallucinations (60%), and auditory hallucinations (60%) were the most common psychotic symptoms documented. All children were initially treated with an antipsychotic medication. Seven children were maintained on an atypical antipsychotic during their hospitalization. Two children had extrapyramidal signs, but no other adverse events were documented. All children were improved at discharge, and 40% had complete resolution of psychosis; 8 of the 10 patients were discharged on a psychotropic medication. DISCUSSION: Psychotic manifestations associated with severe disease presentations were successfully treated by child psychiatrists. Atypical antipsychotics were well-tolerated and used as an adjunct to immunosuppressive regimens in these patients. Prospective studies are necessary to improve the care of children and adolescents with SLE and severe psychiatric manifestations.

BACKGROUND: The Global Assessment of Functioning (GAF) scale is widely used in psychiatry, yet it has certain drawbacks. OBJECTIVE: The authors seek to generate further discussion and research around developing an improved successor to the GAF. METHOD: The authors used the Apgar scale as a template for constructing a possible successor to the GAF. Consulting with 16 colleagues, they selected 5 domains that were felt to be central to functioning in psychiatric patients. Psychiatrists in diverse clinical settings then completed both a GAF and a Psychiatric Apgar scale on 40 patients. RESULTS: The two scales were found to agree significantly. Use of the Psychiatric Apgar, however, provides clearer guidance about assessing functioning. CONCLUSION: The GAF was a brilliant addition to psychiatric practice. As we develop the next Diagnostic and Statistical Manual, it is pertinent to ask whether the GAF approach could be optimized even further by applying the lessons of Virginia Apgar.