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The authors reviewed charts of 100 patients receiving total parenteral nutrition (TPN) and 100 control patients with similar diagnoses who did not receive TPN. In addition, 30 patients were studied with a structured interview and a psychiatric questionnaire. Organic brain syndromes and other confusional states were no more common in the patients on TPN than in the controls, and hyperalimentation did not appear to be a determining factor in the onset of psychosis or depression. Two dangers of TPN, apparently unreported previously, were noted. First, the use of hyperalimentation as primary treatment for anorexia nervosa (rather than as an adjunct to psychiatric therapy) can have serious consequences, such as cerebellar degeneration and suicidal ideation. Second, psychiatric disturbances in caretakers can endanger patients’ lives.

One hundred ninety-five consecutive psychiatric outpatients were surveyed for covert drug abuse by a standardized technique for determining opiates, cocaine, barbiturates, and amphetamines in urine samples. On the basis of demographic variables, diagnostic information, and treatment course, patterns of abuse were defined for the 13.3 per cent with positive test results. Covert abusers demonstrated a higher incidence of adverse drug reactions and a less favorable therapy course than controls. Covert abuse was meaningfuly related to misdiagnosis, management problems, and therapist's response. Demographic variables and patient reports of previous abuse were not found to be reliable predicators of covert drug abuse. Urine screening for drug use is recommended as an aid to proper diagnosis of psychiatric outpatients that present diagnostic questions.

(1979). Relationship of Psychiatric I1lness to Drug Abuse. Journal of Psychedelic Drugs: Vol. 11, No. 4, pp. 337-342.

One-hundred and ninety-five consecutive psychiatric outpatients had urine sampled for the presence of opiates, cocaine, barbiturates, and amphetamines. All patients had demographic variables, diagnostic information, and treatment course analyzed in a blind fashion using preselected criteria. Patterns of abuse were defined for the 13.3% of the total sample who were covert abusers. An analysis of diagnostic accuracy for abusing and nonabusing populations indicated that covert abuse markedly distorted diagnosis and management. The study indicates that demographic variables and previous history were not reliable predicators of covert abuse. Drug abuse was a major factor in distorting the accuracy of diagnosis. Drug abusers were significantly less likely to improve with therapy than were nonabusers. Barbiturate abusers were most likely to suffer from adverse drug reactions. Urine screening for drugs was the single most valuable diagnostic tool and was felt to be indicated in all cases where diagnostic confusion was present. Therapists saw the covert abuser as sick out of proportion to their social behavior, were perplexed and frightened by these patients' dependency, and perceived them as too brittle for therapy. Therapists behaved very differently with these patients than with diagnostically matched controls. They misdiagnosed them four times more often, missed appointments with them seven times more often, and were ten times more likely to refer them to another therapist or agency. Therapist anxiety and "flight from therapy" with covertly abusing patients are discussed.

This study suggests that patients receiving daily doses of 40 mg of prednisone or its equivalent, are at greater risk for developing steroid psychosis. Psychotic reactions were twice as likely to occur during the first 5 days of treatment as subsequently. Premorbid personality, history of previous psychiatric disorder, and a history of previous steroid psychosis did not clearly increase the patient's risk of developing psychotic reaction during any given course of therapy. Steroid psychoses present as spectrum psychoses with symptoms ranging from affective through schizophreniform to those of an organic brain syndrome. No characteristic stable presentation was observed in these 14 cases reported here. The most prominent symptom constellation to appear some time during the course of the illness consisted of emotional lability, anxiety, distractibility, pressured speech, sensory flooding, insomnia, depression, perplexity, agitation, auditory and visual hallucinations, intermittent memory impairment, mutism, disturbances of body image, delusions, apathy, and hypomania. Phenothiazines administered in average daily doses of 212 mg produced excellent response in all patients studied. Of particular note was the fact that tricyclic antidepressants produced an exacerbation or worsening of the clinical state in all patients to whom they were administered.

(1978). Anticholinergic Delirium: Etiology, Presentation, Diagnosis and Management. Journal of Psychedelic Drugs: Vol. 10, No. 3, pp. 237-241.

(1978). Intoxication with Angel's Trumpet: Anticholinergic Delirium and Hallucinosis. Journal of Psychedelic Drugs: Vol. 10, No. 3, pp. 251-253.

A review of mental health prevention programs across the country revealed that less than 10% were directed to the elderly and that only 5% dealt with substance abuse in geriatrics. The majority of existing programs rely on one of three primary approaches: 1) self awareness; 2) consumer education; or 3) community referral following recognition of a defined problem.

The authors studied 100 state hospital psychiatric patients consecutively admitted to a research ward who were screened to eliminate physical illness before admission. They found an unusually high incidence of medical illness: 46% of these patients had an unrecognized medical illness that either caused or exacerbated their psychiatric illness, 80% had physical illnesses requiring treatment, and 4% had precancerous conditions or illnesses. A workup consisting of psychiatric and physical examination, SMA-34, urinalysis, ECG, and EEG after sleep deprivation identified over 90% of medical illnesses present in this population. The authors suggest that such a battery be part of the routine workup for all hospitalized psychiatric patients.

This review of the literature indicates that the incidence of psychiatric reactions to prescription and nonprescription respiratory drugs, such as decongestants, bronchodilators, expectorants, cough suppressants, and related agents, is low. When these reactions do occur they are most likely to appear in patients who are chronic users of these preparations, are overmedicated, or are chronic drug abusers in general. The authors found reports of toxicity to be in general scarce and poorly defined. A careful drug history with inquiry specifically directed at use of these agents is recommended when searching for possible causes of psychiatric reactions, in particular CNS stimulation, anxiety, and a nervous aspect to behavior.

The potentiation of the anticholinergic effects of one drug by another is frequently overlooked as a cause of acutely developing psychosis. This is not surprising considering that more than 600 drugs with significant anticholinergic properties are currently commercially available (Alpern and Marriot, 1973). This paper defines the central anticholinergic syndrome (CAS), its forms of presentation, etiology, pharmacology, and management.

The authors report on the role and functions of a nurse-consultant on an expanding psychiatric consultation-liaison service. One hundred consecutive requests for intervention by a nurse were compared with 100 consecutive requests for psychiatric intervention. Psychiatrists saw 3½ times as many patients on critical care units as did the nurse-consultant. Patient withdrawal and depression were the prime reasons stated for requesting consultation with the nurse, but 24% of the cases seen by the nurse focused on issues of death and dying or on the need for staff or family support, areas in which formal psychiatric intervention was not routinely requested.

Pharmacologic advances provide the physician with a two-edged sword, for while the efficacy of his treatment increases, the iatrogenic illnesses produced by his therapeutics also increase. Adverse drug reactions represent a major cause of iatrogenic illness. It is estimated that one-and-one-half million patients experience a significant adverse drug reaction, at a cost of $3,000,000,000 annually. Such patients represent 5 percent of all hospital admissions and account for 14.3 percent of all hospital days. Of the individuals requiring hospitalization for an adverse drug reaction, 30 percent will experience a second such reaction while hospitalized. Of patients hospitalized for other reasons, 18 to 30 percent will develop an adverse drug reaction during their hospital stay. If such a reaction occurs, the patients’s hospital days will double. Five percent of all hospital deaths are directly attributable to adverse drug reactions (Cluff, 1971; Cluff, 1967; Melmon, 1971).

One-hundred years ago, Sir William Osier made reference to the physician who practices “a sort of pop-gun pharmacy hitting now the malady and again the patient, he himself, not knowing which.” Today we must also be concerned about the patient turning that pharmacologic pop-gun against himself by using one of the 100,000 available over-the-counter drugs (American Pharmaceutical Association, “Handbook of Non-Prescription Drugs,” 1973).

The correlation between drug abuse and intrapsychic problems is not a new issue as can be substantiated by the number of specialty units designated for the treatment of drug and alcohol abuse. The psychiatric literature emphasizes specialization theories regarding drug abuse as a specific form of mental illness. A review of current literature reveals a preponderance of articles dealing with specific psychiatric symptomatology caused by the use of particular substances. Few articles examine the prevalance of substance abuse in psychiatric patients carrying unrelated diagnoses. Those studies which have been done indicate a wide range of prevalence figures for drug abuse, 31%–78%, in selected psychiatric populations (Butzer and Cline, 1974; Fisher et al, 1975; Westermeyer and Walzer, 1975; Blumbert et al, 1971; Hall et al, in press; Cohen and Cline, 1970; Whitlock et al, 1967). The majority of these studies have focused on the young, ages 15–25, rather than considering the psychiatric population as a whole.

The abuse of “legally available” hallucinogenic plants in this country is increasing, particularly among adolescents (Hall et al., 1977). Throughout the southeastern United States the use of Angel’s Trumpet (Datura suaveolens) as a legal hallucinogen is becoming a significant problem.

This study reports on a survey of all Boards of Medical Examiners in the 50 United States, pertaining to actions taken for physician drug abuse. During the year 1976, we could obtain verification of only 37 actions taken against American physicians for drug abuse; in contrast, 142 actions were taken in Canada the previous year. Response rate to the questionnaire was 72 per cent, however, only 18 per cent of the responses gave actual figures regarding action taken. The study also surveyed legal reporting requirements for physician drug abusers in the United States. Factors affecting therapeutic management of physician abusers are discussed in light of difficulties encountered by therapists and peers. Collective data from the authors' treatment of eight physician abusers are reported. Physician abuse is a significant but under-reported problem. Without an impaired physician program, colleagues have difficulty in dealing with physician drug abuse which is characteristically of long duration and known to spouses and colleagues. Few physician abusers voluntarily seek treatment. This study emphasizes the need for continued support, and the development of impaired physician programs. A discussion relevant to predisposing causes, effect of the abuse on the practice of medicine, family stress, and outcome, is undertaken. A management approach for the physician abuser is outlined.

A retrospective analysis found that 25 (44%) of 56 patients diagnosed as having systemic lupus erythematosus (SLE) had psychiatric symptoms at or before the time of diagnosis; 14 (25%) of the 56 were classified as psychotic. While interviews conducted with 19 of the 25 patients revealed no single long-term symptom, insomnia, depressed mood, emotional lability, nervousness, confusion, and diminished concentration were noted frequently. Socially active patients fared better than those who remained isolated. Patients who had experienced a psychotic episode were as well-adjusted on follow-up as those with no history of psychosis. This finding suggests that residual psychiatric effects are not caused by the “lupus psychosis”.

• One hundred patients of lower socioeconomic class were intensively evaluated medically on a research ward for the presence of unrecognized medical illnesses that might have affected their hospitalization. Forty-six percent were thought to have medical illnesses that directly caused or greatly exacerbated their symptoms and were consequently responsible for their admission, while an additional 34% of patients were found to be suffering from a medical illness requiring treatment. A diagnostic battery of physical, psychiatric, and neurologic examinations, coupled with a 34-panel automated blood analysis, complete blood cell count, urinanalysis, ECG, and sleepdeprived EEG established the presence and nature of more than 90% of the illnesses detected, and is therefore recommended as an initial evaluation battery, particularly for patients facing involuntary commitment to a mental hospital.