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Carisoprodol is a commonly used centrally acting muscle relaxant. A number of case reports have suggested that the drug may have abuse potential, presumably because it is metabolized to the anxiolytic drug, meprobamate, which is a controlled substance at the federal level. Two recent case reports described symptoms of withdrawal after the cessation of carisoprodol. We present two additional cases that support the concept of a withdrawal syndrome with this drug. Symptoms of carisoprodol withdrawal include anxiety, tremulousness, insomnia, jitteriness, muscle twitching, and hallucinations. These symptoms are most likely caused by withdrawal from the meprobamate that accumulates after large amounts of carisoprodol are ingested. Although carisoprodol is not a controlled substance at the federal level, clinicians should be aware of its significant potential for abuse.

The consultation-liaison (C-L) psychiatry services of seven university teaching hospitals in the United States, Canada, and Australia (the MICRO-CARES Consortium) used a common clinical database to examine 1039 consecutive referrals. A diagnosis of adjustment disorder (AD) was made in 125 patients (12.0%); as the sole diagnosis, in 81 (7.8%); and comorbidly with other Axis I and II diagnoses in 44 (4.2%). It had been considered as a rule-out diagnosis in a further 110 (10.6%). AD with depressed mood, anxious mood, or mixed emotions were the commonest subcategories used. AD was diagnosed comorbidly most frequently with personality disorder and organic mental disorder. Sixty-seven patients (6.4%) were assigned a V code diagnosis only. Patients with AD were referred significantly more often for problems of anxiety, coping, and depression; had less past psychiatric illness; and were rated as functioning better--all consistent with the construct of AD as a maladaptation to a psychosocial stressor. Interventions were similar to those for other Axis I and II diagnoses, in particular, the prescription of antidepressants. Patients with AD required a similar amount of clinical time and resident supervision. It is concluded that AD is an important and time-consuming diagnostic category in C-L psychiatry practice.

Interventions recommended by consultation-liaison psychiatrists for inpatients they diagnosed as having DSM-III-R organic mental disorder (OMD) were studied to see to what extent specific variables distinguished the OMD patients and differentiated the subgroups of patients with OMD. Prospective data and Mini-Mental State Exam (MMSE) scores on 625 consecutive referrals at 3 general hospitals in Australia and the United States were collected by using the MICRO-CARES database system. The OMD group differed from the other patients because they were significantly more likely to have been referred for "organic brain syndrome" or "agitation," had less mood disorder and lower MMSE scores, and received more recommendations for antipsychotics and for ward-environment manipulation and fewer recommendations for psychological management. The many differences among the OMD subgroups were also consistent with their DSM constructs. A pilot exploration of the validity of the DSM-IV constructs of cognitive disorder and its subgroups performed on the redistributed data suggested that these constructs have similar usefulness.

No current system of computerized data entry of clinical information in consultation-liaison (C-L) psychiatry has been well received or has demonstrated that it saves the consultant's time. The inability to achieve accurate, complete, systematic collection of discrete variables and data entry in the harried C-L setting is a major impediment to the advancement of the subspecialty and health services research. The hand-held Notebook computer with Windows PEN ENTRY MICROCARES capabilities has permitted one-time direct entry of data at the time of collection at the patient's bedside. Variable choice and selection enhances the completeness and accuracy of data collection. For example, ICD-9, Axis III diagnoses may be selected from a "look-up" which at the same time automatically assigns the appropriate code and diagnostic-related groups, (DRG) number. A patient narrative can be typed at the nurse's station, a chart note printed for the medical record, and the MICRO-CARES literature database perused with the printing of selected citations, abstracts, and in some cases experts' commentaries for the consultee. The consultant's documentation time is halved using the NOTEBOOK WINDOWS PEN ENTRY MICRO-CARES software, with the advantage of more accurate and complete data description than with the traditional handwritten consultation records. Consultees preferred typewritten in contrast to handwritten notes. The cost of the hardware (about $2000) is less than that of an optical scanner, and it permits report generation and archival searches at the nurses' station without returning to the C-L office for scanning. Radio frequency or ethernet download from the Notebook permits direct data transfer to th C-L office archive computer.

International discussions of public health policy strategies in developing countries have been characterized by strong and conflicting positions. Differences regarding the means of health sector improvement can often be traced to differences about the ends, that is, the goals of the health sector. Three types of health sector goals are reviewed: health status improvement, equity and poverty alleviation, and individual welfare (utility) improvement. The paper argues that all three must be considered in developing health sector reform strategies in all countries. Highly normative policy positions often can be attributed a unidimensional affiliation with one health sector goal and denial of the relevance of the others. The current global interest in using cost-effectiveness analysis to set national health priorities is assessed in light of this eclectic approach. Examples are provided of how a health sector strategy based on cost-effectiveness would give sub-optimal solutions. These examples include situations where a private health care sector exists and provides some degree of substitution for publicly provided services; significantly high income elasticities exist for health care such that higher income beneficiaries may differentially capture public subsidies; and market failures exist in insurance. It is argued that these conditions are virtually universal in developing countries. Thus, rational policy development should explicitly consider multiple goals for the health sector.

Several investigations of interventions with psychiatric and medical comorbidity (CM) in the medical inpatient setting have been reported. These studies include psychiatric liaison screening and interventions, psychosocial screening, and standard consultation. The studies had a variety of outcome variables: 1) altered psychiatric morbidity; 2) lag time to identification of CM; 3) lag time to referring to mental health disciplines; 4) cost offset; and 5) discharge placement. Methodological and design problems confound many of the results, in particular, the lack of random control procedures. However, similarity of findings of the frequency of CM in the inpatient setting and patient response to early detection and treatment should stimulate further research into the effects of psychiatric interventions in the acute inpatient medical setting.

This paper explores aspects of the need for clinical database management systems that permit ongoing service management, measurement of the quality and appropriateness of care, databased administration of consultation liaison (C-L) services, teaching/educational observations, and research. It describes an OPTICAL SCAN databased management system that permits flexible form generation, desktop publishing, and linking of observations in multiple files. This enhanced MICRO-CARES software system--Medical Application Platform (MAP)--permits direct transfer of the data to ASCII and SAS format for mainframe manipulation of the clinical information. The director of a C-L service may now develop his or her own forms, incorporate structured instruments, or develop "branch chains" of essential data to add to the core data set without the effort and expense to reprint forms or consult with commercial vendors.

To examine those patients referred to psychiatry for the "problem of coping," a structured clinical databased management system--MICRO-CARES--was employed to identify the frequency, demographic characteristics, psychiatric diagnoses, psychosocial interventions, use of psychopharmacology, number of follow-up visits, and discharge placement of these referrals. Consultations totaling 1,157 from July 1, 1988 through January 1, 1990 were divided into two groups and compared: "Not coping" (N = 456, 28.5%) and "others" (N = 701, 61%). Those with a "problem in coping" more often had no Axis I diagnosis (p = 0.001), or were described as adjustment disorders (p = 0.0001). Fewer recommendations were made for those with a coping problem, although lag time (admission date to request for consultation), number of follow-ups, and discharge placement were not significantly different between the two groups. Stepwise logistic regression analyses revealed that the aged had lesser risk for being referred with a coping problem; those who were white, had their own income, experienced greater stress prior to hospitalization (Axis IV), and had higher functioning during the last year (Axis V) were at greater risk.

An important source of failure in markets and justification for government intervention in the health sector of LDCs is imperfect information. Pharmaceutical use is one area in which widespread problems have been noted [1, 2] with substantial misuse, improper diagnosis and problems of compliance noted among both the population at large and health care providers, presumably due to a lack of information concerning appropriate use. One possible instrument vis-a-vis the regulation of pharmaceuticals in LDC's (and in developed countries as well) is the decision by public health officials to make a particular drug available over the counter (OTC) to consumers or to require a prescription from a licensed professional. The choice is one of balancing two competing risks. On the one hand, allowing self-prescription by the consumers who do not have medical training risks gross errors of diagnosis and mistaken prescriptions with possibly serious health consequences. On the other hand, requiring the intervention of a skilled professional runs the risk that the patient does not receive the appropriate, potential life saving, drug at all. With medical personnel in very short supply in many parts of the developing world, the real cost (including travel time and expense) of visiting licensed medical facilities can be prohibitively high. This paper presents a very general methodology for evaluating the tradeoff between these competing risks. The problem can be considered one of determining the value of information (in the form of a more accurate diagnosis through the intervention of a skilled professional) as a particular (and costly) mechanism for obtaining this information.(ABSTRACT TRUNCATED AT 250 WORDS)

Funding for consultation-liaison (C-L) psychiatry remains an overriding obstacle to its implementation and practice. Several methods have been described to access funds for this subspecialty of psychiatry, but none has been enacted as a policy by third party payers to reimburse adequately for the service. In addition, although the consultation portion of the effort can be reimbursed in part in some cases through fee for services, the liaison portion is dependent on the donation of psychiatry time or the largesse of the host department. The efforts at Stanford to capitalize on the findings that psychiatric and medical comorbidity results in prolonged length of hospital stay and increased health resource utilization suggest that specific DRGs would be important patient groups to screen and charge for psychiatric services. Furthermore, DRGs that are accompanied by a high frequency of psychiatric comorbidity are a "target" for an additional funding aliquot to assess and manage the patient's psychiatric status.

Objective: The authors hypothesized that psychiatric liaison screening of elderly patients with hip fractures would shorten the average length of hospital stay and increase the proportion of patients who returned home after discharge., Method: The study was performed at Mount Sinai Medical Center in New York and Northwestern Memorial Hospital in Chicago. The subjects were 452 patients 65 years or older who were consecutively admitted for surgical repair of fractured hips. During a baseline year the patients received traditional referral for psychiatric consultation. During the experimental year all the patients at Mount Sinai and the patients on one Northwestern Unit were screened for psychiatric consultation., Results: The patients who received psychiatric liaison screening had a higher consultation rate than those who received traditional consultation. The rates of DSM-III disorders in the experimental year were 56% at Mount Sinai and 60% at Northwestern. The mean length of stay was reduced from 20.7 to 18.5 days at Mount Sinai and from 15.5 to 13.8 days at Northwestern, resulting in reductions in hospital costs ($647/day) of $166,926 and $97,361, respectively. Fees generated from Medicare service delivery could have paid for the $20,000 psychiatric intervention cost at each site. There was no difference, however, between the two years in the discharge placement of patients., Conclusions: Admission psychiatric liaison screening of elderly patients with hip fractures results in early detection of psychiatric morbidity, better psychiatric care, earlier discharge, and substantial cost savings to the hospital.

Despite their importance, the nature and context of referral patterns among mental health disciplines in the general hospital has not been sufficiently explored. This study focuses on consultation-liaison (C-L) psychiatry patterns of referral to social work services (SWS). From a structured data base of 1170 consults, it was observed that C-L referred 24% of the cases seen by psychiatry. Psychiatry was more likely to refer those who are: female (p = less than 0.05), living with others (p = less than 0.05), described as less urgent (p = less than 0.05), diagnosed with personality disorders (p = less than 0.01), under greater psychosocial stress (Axis IV) (p = less than 0.001), and evaluated as having better functional status (Axis V) (p = less than 0.001). Regression analysis revealed that four variables had the greatest impact on differentiating those C-L referred to SWS from the "others": 1) constant observation recommended (log -586, p = 0.0001); 2) type of psychiatric management (log -573, p = 0.0001); 3) Medicaid insurance (log -564, p = 0.0001); and 4) original referral for the consultation was the refusal of tests or medical treatment (log -559, p = 0.002).

Convincing evidence exists that psychosocial factors have a major impact on both outcome and costs in the medical/surgical services in general hospitals. This paper describes the Human Services Department's impact on social work and consultation-liaison psychiatry, using a data-based management system across five specialties: 1) social work; 2) consultation-liaison psychiatry; 3) supportive care (hospice); 4) home care (home health discharge planning); and 5) pastoral care, which offers opportunities for research and quality assurance monitoring. Time spent in service delivery was used to estimate the cost per hour: 1) pastoral care $96; 2) social work $36; 3) consultation-liaison psychiatry $59; 4) home care $49. Referral to social work was preferred for a range of family and discharge planning services. Consultation-liaison services were preferred for depression, paranoid behavior, and management problems. Referral overlap was noted for "coping with diagnosis" for social work and consultation-liaison psychiatry. Using a computerized data base format for documenting the referral process, work accomplished, and time spent among those services providing mental health care in the general hospital permits the observation of redundancy of services delivered and their costs.

The psychiatric consultant is dependent upon the consultee for the implementation of many of his or her recommendations. Therefore, research as to the fate of recommendations suggested to the consultee is of eminent importance. The concordance (performing a suggested recommendation) paradigm, as developed by Popkin et al. is further elaborated for biologic and psychologic, as well as social, recommendations that were described in an earlier study. The results of the assessment of consultee concordance for 317 psychiatric consultation patients are described. Specific attention is directed to the development of criteria, the method of assessment, the mechanisms underlying nonconcordance, and the description of methods to enhance concordance. This study indicates that assessment of and control for concordance needs to be an integrated part of all consultation/liaison psychiatry (C/L) intervention studies in order to document the actual implementation of recommendations, accurately assess the findings of C/L outcome research, and avoid error measurement.

In a previous study, a checklist and a schema for operationalized interventions have been described. In this study, these operationalized interventions have been used in clinical practice in 820 cases. In 287 cases (35%), recommendations focusing on the medical treatment, other than diagnostic action (41%) and medication (68%), were provided. This emphasis on the intensity of medical treatment is an unreported finding. The further distribution of recommendations over the different intervention domains was: obtaining additional psychosocial information, 30%; psychosocial management on the ward, 61%, specifically its organization; discharge planning, 41%; and aftercare management, 24%. Recommendations infrequently used included: monitoring of cognition and behavior, referrals to occupational therapy and alcohol- and drug-related facilities, and a detailed specification of postdischarge care. Since consultee concordance with the consultant's recommendations is important to treatment outcome, this method of a systematic recording of operationalized recommendations is a first step toward enhancing the evaluation of treatment recommended and provided by consultation/liaison (C/L) psychiatrists. Moreover, these operationalized recommendations help advance the specification of protocols for psychiatric intervention studies.

The microcomputer allows for the design of a system that functions integrally with both the day-to-day and long-term needs of a consultation-liaison psychiatric service. This article describes a microcomputer system and data structure that can accomplish many of the same research tasks as a minicomputer system. In addition, the same data item inputs can be used to develop management reports that can facilitate the administrative as well as the pedagogic needs of a consultation-liaison service. Because of the daily availability and review of output reports, supervisors' corrections are made that enhance the reliability of the data. The program format provides 1) an intake form with pertinent identifying demographic data; 2) an activity file that contains every encounter between the consultant and the patient as well as research, supervisory, and liaison activities (which permit cost-effectiveness analysis); 3) a master clinical data base containing 255 variables for each case seen; 4) a computer-generated chart note; 5) letters to referring physicians; 6) clinical activity descriptions for billing; and 7) a file for pertinent literature searches. Since certain analyses may be limited in the microsystem, its interactive capacity with mainframe computers allows for complex functions. The microsystem described presently emphasizes flexibility, accessibility, and step-by-step development of files as needed by a particular consultation-liaison service. Finally, microcomputers are available at a fraction of the cost of the minicomputer or mainframe systems.

This article describes an innovative administrative organization for the delivery of psychologic care in the contemporary teaching hospital that, by combining services under medical leadership, takes an evolutionary beyond multidisciplinary team approaches. The long-range goal of this organization is to provide cost-effective psychosocial services in the general hospital while maintaining the unique role contributions of the participating disciplines. To allow for informed decision making in this process, the initial step has been to establish a collaborative data base for patient and staff tracking, program planning, and evaluation.

This article presents research involving the comparison of levels of occupational stress across multiple units of a large teaching hospital. Using a scale designed to measure a four-component model of occupational stress in medical environments, the results indicated that a significant amount of the variation in this measure was accounted for by the unit on which the respondent worked. There were no significant differences across levels of employment (e.g., housestaff, nurse clinician, registered nurse, licensed practical nurse, clerk).

The impact of psychiatric comorbidity on the length of hospital stay was addressed in a study of all medical/surgical patients discharged in 1984 from the Mount Sinai Hospital in New York City (N = 37,370) and Northwestern Memorial Hospital in Chicago (N = 21,889). At both hospitals the mean +/- SD length of stay of the patients with psychiatric comorbidity was significantly longer than that of the other patients: 19.8 +/- 33.3 versus 9.2 +/- 15.3 days at Mount Sinai Hospital and 13.7 +/- 27.7 versus 8.3 +/- 13.2 days at Northwestern Memorial Hospital. Early identification of patients with psychiatric comorbidity would permit appropriate psychosocial intervention, which might shorten their hospital stays.

The amount of time consultation psychiatrists in a large metropolitan teaching hospital spent providing direct services was studied over 1,104 consecutive consultation cases. Although the majority of cases required less than 5 hours of psychiatric time apiece, more than 10% of these cases each received more than 10 hours of direct services. This finding has important implications for understanding the types of psychiatric services provided to hospitalized medical/surgical patients.

The reliability, validity, and temporal stability of the Geriatric Depression Scale (GDS) were studied in sixty-nine elderly patients who had their broken hips surgically repaired. The GDS demonstrated internal consistency reliability and concurrent validity with the Hamilton Depression Rating Scale. In addition, the GDS was stable across the hospital stay and thus appeared to be less influenced by the patients' acute health status.

A woman with typical symptoms of lithium toxicity had, in addition, severe generalized sensorimotor peripheral neuropathy, which cleared completely as the recovered. Electrodiagnostic studies suggested axonal lesions; autopsy ten months later revealed no residual abnormalities. Previous studies have shown that lithium can affect peripheral nerve function, but this is the first reported case of peripheral neuropathy in association with lithium toxicity.

Three hundred twenty-one patients with traumatic head and spinal cord injuries were studied. Forty-two of these patients (13.1%) received psychiatric consultation services. Two types of consultation patients were identified--one receiving psychiatric consultation services in the acute-care hospital and one receiving psychiatric services in the post-acute care, long-term rehabilitation center. In order to assess the impact of psychiatric co-morbidities on hospital length of stay and charges, 40 consultation patients (23 acute and 17 rehabilitation) were matched to 87 control patients who received no psychiatric services. Matching was done on severity of injury, age, and sex. Psychiatric consultation cases had significantly longer stays than did matched controls. There were no differences on total charges.

Four hundred nineteen consecutive consult cases were studied to determine the relationship of the timing of the consult to hospital length of stay. Results indicated that earlier consultations predicted shorter lengths of stay. Applications of the present methodology to more complex evaluations of psychiatric consultation are discussed.

Although a consortium approach for clinical trials is a common research strategy which has made important contributions in other disciplines in medicine, to date it has not been employed for research efforts in the consultation/liaison setting. There are several reasons for this: the relative newness of the field, lack of administrative control over patient care, and the unavailability of a standard methodology that could be adapted to multiple sites. Four basic research strategies can be employed within the framework of a research consortium to advance scientific knowledge in consultation/liaison psychiatry: 1) prevalence studies of psychiatric morbidity in medical settings; 2) interrelationship among psychiatric and medical conditions; 3) the outcome of psychiatric interventions within medical milieu; and, 4) cost-benefit evaluation. A field-tested computerized database protocol and a software system usable on an office-based microcomputer were employed to obtain standardized data across multiple training sites. The advantages and disadvantages of consortium studies are described.

We report a study of occupational stress in 374 paramedics. Results indicate that this profession experiences a high degree of job-related stress relative to other medical personnel. In a component analysis of this stress the results show that job stress manifests itself as job dissatisfaction, organizational stress, and negative patient attitudes, but not as frequently as somatic distress.

"A commonly cited motive for childbearing in LDCs is the support in old age provided by one's children. Alternative means of retirement support become available as a country develops. This paper presents a simple two period model in which financial institutions are allowed to substitute for children in the provision of this service. The 'quality' of financial institutions is given an operational definition and the hypotheses of the model are tested on a cross-section sample of countries.", (excerpt)

The present study details the development of a stress scale for medical personnel. The Medical Personnel Stress Scale is a 48-item subjective stress measure capable of assessing both organizational and individual dimensions of stress. It demonstrated both the ability to discriminate between divergent medical emergency room organizations and to predict self reported on-the-job difficulties.

Patients with a psychiatric disorder are known to make greater use of medical resources than patients without a psychiatric condition, but the impact of highly prevalent psychiatric illnesses, such as depression, on use of medical resources has not been fully explored. This study assessed the lengths of stay of 92 medical and surgical patients who met DSM-III criteria for depression and the relationship of their length of stay to the timing of psychiatric consultations. The 92 patients were hospitalized significantly longer (a mean of 2.52 days more) than they would have been had their length of stay been determined by their medical diagnosis-related group (DRG). A subgroup of 38 Medicare patients were hospitalized a mean of 5.22 days more than the mean stay allowed by their DRG. Consultations occurring earlier in the hospitalizations were linked to shorter stays.

In light of the increasing emphasis on cost-effectiveness evaluations of consultation-liaison interventions, it becomes important for researchers to be cognizant of the available statistical methods. With this in mind, the present article reviews eight strategies of cost-effectiveness research and discusses their relative strengths and liabilities.