General Psychiatric Hospital Research Articles

The Effectiveness of Electroconvulsive Therapy in Treatment-Resistant Depression

Electroconvulsive therapy (ECT) is a very effective treatment of major depressive disorder. However, its use has been declining over the years in the United Kingdom, where it is now reserved for cases where all other treatment options have failed. We wanted to assess whether ECT is still highly effective in such a severely treatment-resistant population. We report results from an ongoing, prospectively conducted, naturalistic study examining the effectiveness of ECT at a general psychiatric hospital in Cardiff, United Kingdom. We present results on every patient who received ECT between March 2004 and August 2006 for major depressive episodes, had a baseline 24-item Hamilton Rating Scale for Depression (HRSD24) score of greater than or equal to 18 and consented for participation. We analyzed the results of 38 patients who had at least 6 ECT sessions or achieved remission earlier. They had spent on average 14.6 months in their current episodes and 6.2 years of their lifetime in depression. They had failed to respond to an average of 5.4 different pharmacological treatments. Twenty-five patients (65.8%) responded (improvement in HDRS24 of >or=50%) and 21 (53.3%) achieved remission (end point HDRS24 score <or=10 and improvement in HDRS24 of >or=60%). There was no correlation between the number of unsuccessful antidepressant trials and improvement (r = -0.04, P = 0.8). The ECT is still highly effective in severely treatment-resistant patients with major depressive disorder, with more than half of such patients achieving remission.

Trajectoires de soins de patients alcoolodépendants: une étude longitudinale en Suisse italophone

Alcohol abuse predisposes to numerous public health problems leading to important direct and indirect costs. One out of four hospital beds in Switzerland is occupied by a patient presenting a diagnosis of alcohol consumption. The objectives of this retrospective study are firstly to have an overview of the therapeutic orientation of the patients in the existing alcohology network of the canton of Tessin and to analyse the treatment trajectories of the adult hospitalised patients, in the general psychiatric hospital, presenting a problematic alcohol consumption and in particular to evaluate the impact of socio-demographic and clinical factors on the eventual readmissions. The analysis of this longitudinal retrospective study (1995-2000) is based on the data collected from the computerised register of the socio-psychiatric cantonal organisation (OSC) and that of the Centre Ingrado, a centre specialised in alcohology. Two principal results are highlighted. Firstly, two groups of patients can be distinguished by their psychosocial aspects. Secondly, the two groups are distinguished by their post-hospitalisation trajectories. In the first group of patients subjects older than 50 years are overrepresented, those living in companionship as well as those having less antecedents of a specific healthcare. This group was preferentially sent to private practitioners and presented comparatively less rehospitalisations. The second group appears as socially less well integrated, has many antecedents of health care and had longer hospitalisations in 1995.The patients of this second group were addressed to specialised psychiatric health care structures and or those specialised in alcohology. The rehospitalisations were more frequent for patients of the second group. In the appreciation of the results of the study, its limits have to be taken into consideration. On the one hand, it is a retrospective study with the major limiting factor being a limited choice of predictive variables, the indicators of the trajectory of the patient, and on the other hand, the social class. It was not possible during the course of the study to take the social class into account as a predictive variable. Finally, we also lack the data on the eventual deaths, occurring in our cohort, outside the psychiatric hospital, during the observation period of the study. In conclusion, despite the fact that the alcohology network of the canton of Tessin needs in part to be systematised, we can nevertheless note that the existing practices and services are fully convenient. Future conceptualisations ideally need to rest on this experience in privileging mainly a perspective of treatment trajectory and to a lesser extent the option of a sequential episode of treatment.

Psychopathology in adolescent and young adult criminal offenders (15–21 years) in Sweden

This study examined rates of psychopathology among adolescent and young adult serious offenders referred to pre-sentence forensic psychiatric services and compared patterns of psychiatric morbidity with adult forensic referrals and age-matched general psychiatric inpatients. In Sweden, criminal offenders can be referred for an extensive court-ordered pre-sentence inpatient forensic psychiatric examination (FPE). Data on all 3,058 of these offenders (90% male, mean age = 35.3 years) during 1997-2001 were obtained from the National Board of Forensic Medicine. We compared DSM-IV psychiatric diagnoses across age bands 15-17 years (N = 60), 18-21 years (N = 300) and 22 years and older (N = 2,698). Comparative data by age bands were also obtained for inpatient diagnoses among individuals admitted to general psychiatric hospitals. Compared with the adult forensic psychiatric examinees, those aged 15-17 years and 18-21 years had higher rates of depression, and childhood and developmental disorders but lower rates of psychosis, bipolar disorder, and substance use disorders. Compared with general psychiatric inpatients, offenders aged 15-17 years had higher prevalences of depression and attention-deficit or disruptive disorders and lower ones of alcohol and drug misuse disorders. There are significant differences in patterns of psychiatric morbidity in adolescent and young adult offenders that come into contact with psychiatric services compared with older offenders and adolescent psychiatric inpatients. This suggests that the development of health services addressing the psychiatric needs of younger offenders needs to draw on information on their specific mental health needs.

The system of coercive (court mandated) medical measures in the Russian Federation

Coercive treatment (CT) in Russia is a court mandated medical measure applied to persons who committed a punishable dangerous act (SDA) and who are suffering from a mental disorder if it is proved that their dangerousness is due to such disorder. The CT is applied to the irresponsible, to the person fallen ill after having committed the crime, and to the partially responsible. There are four types of CT: 1) the outpatient CT is ordered to the patients who had committed the SDA in an acute psychotic state that has no tendency to be repeated or to the chronically ill patients after inpatient CT (the mean length of stay (LOS) in 2005 was 382.9 days). 2) The CT at a general (low security) psychiatric hospital is given to the patients suffering from a well curable acute disorder or relapse of chronic disorder. These patients are generally well adjusted to living in the community and their dangerousness is associated solely with their psychotic experiences; but their LOS is much longer (428.3 days) than that of the ordinary patients owing to the necessity to obtain a stable remission. 3) The dangerousness of the patients at a specialized (medium secure) hospital is caused by their deficient and personality disorders with antisocial orientations. The developing of socially acceptable stereotypes of conduct requires a long CT (603.4 lays). 4) The patients of a specialized hospital with intensive observation are united by their particular dangerousness associated with mental disorder (aggressiveness, persistent recidivism, severe violation of hospital regimen; the LOS here exceeds 1,226 days). The above mentioned measures function as a system owing to their right choice, the possibility of their successive substitution, and active preventive follow ups after completion of CT. The effectiveness of CT remains moderate: about 1/3 of the discharged patients commit repeated SDA, there is a slow accumulation of long stay patients (10 years or more) in all types of hospitals.

Avatares de la medicalización en América latina 1870–1970 (review)

Reviewed by: Avatares de la medicalización en América latina 1870-1970 Diana Obregón Diego Armus , ed. Avatares de la medicalización en América latina 1870-1970. Colección Salud Colectiva. Buenos Aires: Lugar Editorial, 2005. 304 pp. No price given (paperbound, 950-892-214-1). This collection of ten essays, most of them already published somewhere else in either Spanish, Portuguese, or English, follows the themes of three other compilations published by Diego Armus in the last few years: Gilberto Hochman and Diego Armus, eds., Cuidar, controlar, curar: Ensaios históricos sobre saúde e doença na América Latina e Caribe (2004); Diego Armus, ed., Disease in the History of Modern Latin America: From Malaria to Aids (2003); and Diego Armus, ed., Entre medicos y curanderos: Cultura, historia y enfermedad en la América Latina moderna (2002). The current volume tackles the complex interactions between disease, social representations, medicine, and politics in Argentina, Brazil, and Mexico (one of the articles includes Chile). Three of the essays deal with disease—tuberculosis, Chagas disease, and syphilis—although in very different ways. Armus shows that TB patients in Argentina were far from passive, demanding a specific type of therapy and strongly opposing measures taken by the health authorities. Distancing himself from Foucauldian approaches, Armus seeks to demonstrate that patients' numerous protests prove that however strong it may have been, medical power was counterbalanced. Using concepts from the social studies of science, Simone Petraglia Kropf, Nara Azevedo, and Luiz Otávio Ferreira challenge current approaches to Chagas disease history, analyzing the long process by which it was constructed as a particular entity and [End Page 892] established as a social problem. Not only Chagas was instrumental to this recognition, but also later agents and institutions in both Brazil and Argentina. The papers by Sérgio Carrara on syphilis and by Nísia Trinidade Lima and Gilberto Hochman on the Brazilian hygienic movement are complementary: they both approach the beliefs of the early twentieth-century Brazilian intellectuals and physicians about race, disease, national identity, and the backwardness of the nation. Carrara focuses on intellectual and common representations of syphilis in Brazil—particularly the dispute over its origin, its incidence, and the potential of the Brazilian society to become modern, given the racial mixture of its population. He understands these debates as a partly failed anticolonialist and nationalist strategy of the Brazilian elite in a need to overcome metropolitan pessimistic images of the nation. Lima and Hochman study how the leaders of the Brazilian hygienic movement (1899–1930) dissociated themselves from the polar positive or negative opposites, and made possible the institutionalization of public health as a professional activity. The chapters by Claudia Agostoni and Alexandra Stern on Mexico also converge on medical ideologies/practices, and state formation: Agostoni looks at late nineteenth-century works on hygiene by Mexican physicians who came to believe that the education of women, particularly mothers, in the tenets of hygiene was vital to the progress of the nation. Stern explains the emergence of biotypology in mid-twentieth-century Mexico as a continuation of both the late nineteenth-century cult of the mestizo and the eugenic movement of the 1920s. Mexican biotypologists, using tools such as statistics, sought to convey a less racist viewpoint, but—like their Brazilian peers, as discussed by Carrara and by Lima and Hochman—they faced the logical difficulties of overcoming openly racist European and U.S. medical and social theories. Eric Van Young's article focuses on the general psychiatric hospital of Mexico City in the early twentieth century as a modernizing project, and reasons about the complexity of this topic for a history of the Mexican state, or for a cultural history of the subaltern groups. Susana Belmartino criticizes structuralist approaches to the subject of the emergence of health systems, comparing Argentina, Brazil, and Chile between 1920 and 1970, and the differences of their health arrangements in relation to their particular political organizations. The touching painting of a woman who died of yellow fever in the 1871 Buenos Aires epidemic is the topic of Laura Malosetti Costa's piece. It is intriguing why this otherwise cogent article appears...

Is Neuroimaging's Promise About to Be Realized?

Is Neuroimaging's Promise About to Be Realized?

Revolving door and human resources in a community mental health system

Background and aims:Andalusia is the most highly populated (7,849,799 hab.) region of the Spanish State. It has all the sanitary domains under its own Health Service (Consejeria de Salud), and it has undertaken a deep reorganization of the psychiatric services, establishing a new model based on the mental health communitarian alternative that is already completely implanted. Rates of readmission are a method to assess the quality of care and an important tool in the planning of services of mental health.The aim of this study is to establish if readmission rates are influenced by Human Resources in Psychiatric Community Devices.Part of FIS Project PI05/90061 ‘Patterns of General Hospital Psychiatric Units Overuse’.Method:MBDS is a system of hospital register that gathers all the discharges produced in the andalusian hospitals. It is totally trustworthy from 1995, and we have processed data up to 2004.Our Data Set register 101234 hospital admissions of psychiatric patients.Results:The number of admissions from patients who enter three times or more throughout the year has been: 22.66%(1995); 24.66% (1996); 31.01%(1997); 30.72%(1998); 34.07%(1999); 35.35%(2000); 36.92%(2001); 32.93%(2002); 31.20%(2003) and 29.36%(2004).On the other hand, it has been an increase in Mental Health Human Resources Rates: 24.23-100.000 inhab-(1998); 24.19 (1999); 26.01(2000); 28.04(2001); 29.83(2002); 29.16(2003); 29.34(2004) and 29.90(2005).Conclusion:Increasing human resources in psychiatric community devices do not change revolving-door rates in general hospital acute psychiatric units in a community mental health system.

A Multisite Study of Community Treatment Programs for Mentally Ill Offenders With Major Mental Disorders

This article presents reasons for undertaking “The Comparative Study of the Prevention of Crime and Violence by Mentally Ill Persons” and reasons for decisions regarding the study design and choice of measures. A brief portrait of the forensic patients that have been recruited is also presented. Community treatment programs could offer long-term cost-effective care for offenders with major mental disorders (MMDs). The study aims to identify the necessary ingredients of an effective program. Sites are selected in four countries where identification of most, if not all, persons with MMD who commit crimes within the catchment area was possible. Within each site, two samples of patients with MMD are recruited, one from a forensic hospital and one from a general psychiatric hospital. Assessments are completed prior to discharge. Participants are followed during a 5-year period. Comparisons of the forensic patients recruited in the four sites indicate many more similarities than differences.

An observational study in psychiatric acute patients admitted to General Hospital Psychiatric Wards in Italy

Objectivesthis Italian observational study was aimed at collecting data of psychiatric patients with acute episodes entering General Hospital Psychiatric Wards (GHPWs). Information was focused on diagnosis (DSM-IV), reasons of hospitalisation, prescribed treatment, outcome of aggressive episodes, evolution of the acute episode.Methodsassessments were performed at admission and discharge. Used psychometric scales were the Brief Psychiatric Rating Scale (BPRS), the Modified Overt Aggression Scale (MOAS) and the Nurses' Observation Scale for Inpatient Evaluation (NOSIE-30).Results864 adult patients were enrolled in 15 GHPWs: 728 (320 M; mean age 43.6 yrs) completed both admission and discharge visits. A severe psychotic episode with (19.1%) or without (47.7%) aggressive behaviour was the main reason of admission. Schizophrenia (42.8% at admission and 40.1% at discharge) and depression (12.9% at admission and 14.7% at discharge) were the predominant diagnoses. The mean hospital stay was 12 days. The mean (± SD) total score of MOAS at admission, day 7 and discharge was, respectively, 2.53 ± 5.1, 0.38 ± 2.2, and 0.21 ± 1.5. Forty-four (6.0%) patients had episodes of aggressiveness at admission and 8 (1.7%) at day 7. A progressive improvement in each domain/item vs. admission was observed for MOAS and BPRS, while NOSIE-30 did not change from day 4 onwards.The number of patients with al least one psychotic drug taken at admission, in the first 7 days of hospitalisation, and prescribed at discharge, was, respectively: 472 (64.8%), 686 (94.2%) and 676 (92.9%). The respective most frequently psychotic drugs were: BDZs (60.6%, 85.7%, 69.5%), typical anti-psychotics (48.3%, 57.0%, 49.6%), atypical anti-psychotics (35.6%, 41.8%, 39.8%) and antidepressants (40.9%, 48.8%, 43.2%). Rates of patients with one, two or > 2 psychotic drugs taken at admission and day 7, and prescribed at discharge, were, respectively: 24.8%, 8.2% and 13.5% in mono-therapy; 22.0%, 20.6% and 26.6% with two drugs, and 53.2%, 57.8% and 59.0% with > two drugs. Benzodiazepines were the most common drugs both at admission (60.0%) and during hospitalisation (85.7%), and 69.5% were prescribed at discharge.Conclusionpatients with psychiatric diseases in acute phase experienced a satisfactory outcome following intensified therapeutic interventions during hospitalisation.

The influence of staffing levels on the use of seclusion

This study focussed on the relationship between the use of seclusion and staff characteristics, such as number of nurses on shift, male–female staff ratio, level of education and level of work experience. A retrospective analysis of staff characteristics was applied to administrative data from ten wards in four mid-sized general psychiatric hospitals in the Netherlands. The data show that two variables were associated with seclusion rates: the male–female staff ratio and the variability in team's work experience. More female and less male nurses in a shift and less variability in team's work experience predicted an increase in seclusion rates.

The Effects of Etomidate on Seizure Duration and Electrical Stimulus Dose in Seizure-resistant Patients During Electroconvulsive Therapy

Methohexital used to be the preferred anesthetic used in electroconvulsive therapy (ECT). Since 1999, there have been supply problems for this drug, and there has been no clear guidance regarding which anesthetic should be used preferably in ECT. Most clinics use thiopental or propofol, although these drugs may increase the seizure threshold. We investigated if etomidate improves seizure duration compared with thiopental in cases where eliciting seizures becomes problematic. During our routine delivery of ECT at a general psychiatric hospital in Cardiff, UK, we observed 5 patients who had ECT courses with thiopental and did not achieve adequate seizure duration despite very high electric stimulation. They later relapsed and received second courses of ECT under etomidate. We compared the seizure duration and the electric charge needed to produce the seizures for a total of 46 pairs of ECT sessions given under the 2 anesthetics on the same patients. The average electric stimulation dose required to induce seizures was reduced from 638 to 497 millicoulombs (95% confidence interval, 60-221; P = 0.001). Despite the lower dose, the length of observed seizure duration increased by 10.3 seconds (65%) and that of the electroencephalograph-recorded duration increased by 8.7 seconds (41%) (P < 0.001). Etomidate has a distinct advantage over thiopental in producing seizures of adequate duration during ECT and should be used as the first-line measure in augmenting seizures in patients who have very high seizure thresholds.

A Retrospective Controlled Study into Memory Complaints Reported by Depressed Patients After Treatment with Electroconvulsive Therapy and Pharmacotherapy or Pharmacotherapy Only

Few studies have been conducted comparing complaints of memory problems using objective and subjective memory scales in depressed patients who received electroconvulsive therapy (ECT) + pharmacotherapy or treatment with pharmacotherapy only. Patients who suffer from depression according to the Diagnostic and Statistical Manual of Mental Disorder (Fourth Edition) criteria and who were admitted within the past 5 years before this study in a general psychiatric hospital were screened for inclusion. Objective retrograde amnesia was assessed using the Autobiographical Memory Interview and the Amsterdam Media Questionnaire (AMQ). Subjective retrograde amnesia was assessed using the Squire Subjective Memory Questionnaire and the ECT Retrograde Amnesia and Perception Scale (ERAPS), a newly developed scale. Twenty of the 84 patients who received ECT + pharmacotherapy and 30 of the 196 patients who received pharmacotherapy only participated in the study. Patients' ERAPS memory scores were compared with proxies' ERAPS memory scores of the patients to assess the reliability of memory complaints. The ECT + pharmacotherapy group was found to suffer more from memory problems using the AMQ 1990 test. There was also a difference for the proxy's ERAPS memory score, reflecting the conviction of proxies from the ECT + pharmacotherapy patients that these patients suffer more memory problems due to the illness, treatment with pharmacotherapy, or ECT. The differences could not be explained by the influence of determinants for retrograde amnesia. ECT + pharmacotherapy patients did not attribute their memory problems mainly to ECT but put equal "blame" on the depressive illness, treatment with pharmacotherapy, and ECT. The analyses suggest that the AMQ 1990s test is (more) sensitive in registering retrograde amnesia than the other scales used in the study.

Discharge Against Medical Advice From Inpatient Psychiatric Treatment: A Literature Review

A comprehensive review of the literature examined discharge from inpatient psychiatric settings against medical advice (excluding elopements) over the past 50 years. Specifically, definitions, prevalence, predictors, temporal patterns, consequences, and interventions pertaining to such discharge were explored. The authors searched the PubMed and PsycINFO databases and selected articles for review if studies had been conducted in an inpatient setting or included discharge against medical advice as one of the aims or results and if findings were based on formal statistical analyses. Sixty-one articles met the selection criteria. Prevalence of discharge against medical advice ranged from 3 to 51 percent and increased over time. Discharge against medical advice was most commonly predicted by patient factors, such as young age; single marital status; male gender; comorbid diagnosis of personality or substance use disorders; pessimistic attitudes toward treatment; antisocial, aggressive, or disruptive behavior; and history of numerous hospitalizations ending in discharges against medical advice. It was also predicted by provider variables, such as failure to orient patients to hospitalization and failure to establish a supportive provider-patient relationship, and by temporal variables, such as evening and night shifts. Outcomes of patients discharged against medical advice were characterized by poor outcomes in several domains of functioning and more frequent rehospitalizations. Prediction of patients at risk of discharge against medical advice is possible with several defined variables. Awareness of the factors involved in discharge against medical advice should facilitate clinical decision making and the development of successful interventions for high-risk patients.

Postictal psychosis: presymptomatic risk factors and the need for further investigation of genetics and pharmacotherapy

BackgroundPostictal psychosis (PIP), an episode of psychosis occurring after a cluster of seizures, is common and may be associated with profound morbidity, including chronic psychosis. Symptoms are often pleomorphic, involving a range of psychotic symptoms, including hallucinations and disorders of thought. PIP is treatable and may be averted if presymptomatic risk factors are considered in susceptible patients and treatment is initiated.Case presentationIn this report, we present an illustrative case of PIP. The patient, Mr. R, presented to our emergency room with delusions and disordered thought process following a cluster of seizures. He recovered after admission, sedation and treatment with antipsychotic medication.DiscussionA list of presymptomatic risk factors is established based on review of current literature. Identification of such risk factors may potentially help with prophylactic treatment; however, little empirical research exists in this area and treatment guidelines are thus far largely based on expert opinion. Further, while the neurobiology of schizophrenia is advancing at a rapid pace, largely due to advances in genetics, the pathophysiology of PIP remains largely unknown. Considering the progress in schizophrenia research in the context of the clinical features of PIP and existing studies, potential neurobiological mechanisms for PIP are herein proposed, and further genetic analyses, which may help identify those susceptible, are warranted.ConclusionWhile PIP is an important problem that may present first to general hospital psychiatrists, as in the case presented, this topic is under-represented in the medical psychiatry literature. As discussed in this article, further research is needed to develop presymptomatic screens and treatment pathways to help prevent morbidity.

Tools for case finding and care coordination in a service for elderly cancer patients

In this presentation I will address two common problems in geriatric medicine: how to select elderly cancer patients who need specialised interventions and how to organise complex care. Chronological age, though often used, seems not the best selection criterion. Instead, the concept of frailty can be used, which indicates a bundle of losses in resources. As expected, frailty relates more strongly to a decline in self-management abilities and case complexity than chronological age. Therefore, using frailty to select older people at risk is an improvement compared to selecting people for interventions only by their chronological age, because it is likely to yield a more accurate selection. As the instrument we developed to measure frailty (the Groningen Frailty Indicator) is short and easy to use, it seems a reasonable and manageable alternative for using chronological age as selection criterion for interventions. The second problem in dealing with so-called complex patients, especially the frail elderly, lies in the need of coordination of fragmented care. Coordination, which integrates the different medical, including psychiatry, and paramedical disciplines and guarantees communication between health-care professionals. To achieve this goal we have implemented the INTERMED, a method developed over the last decade by an international group of general hospital psychiatrists and geriatricians, to assess the bio-psycho-social care needs of complex patients.

"Difficult Patients" in Mental Health Care: A Review

"Difficult Patients" in Mental Health Care: A Review

Admissions to five General Hospital Psychiatric Wards in Naples, Italy

Admissions to five General Hospital Psychiatric Wards in Naples, Italy

PSYCHIATRIC HOSPITAL CAPACITY, HOMELESSNESS, AND CRIME AND ARREST RATES*

As a result of developments in pharmacology, stricter standards for involuntary commitment, and changes in public expenditures, there has been a dramatic decline in the capacity of public psychiatric hospitals to maintain America's most severely mentally ill. Psychiatric deinstitutionalization has led to an increased presence of persons with mental illness in urban areas, many “falling through the cracks” of community‐based services. This is hypothesized to have contributed to homelessness, crime, and arrests. Individual‐level research has documented disproportionate and increasing numbers of mentally ill persons in jails and prisons. It has also found higher rates of violence and arrest among persons with mental illness compared to the general population. This study takes a macro‐level social control approach and examines the relationships between psychiatric hospital capacity, homelessness, and crime and arrest rates using a sample of eighty‐one U.S. cities. I find that public psychiatric hospital capacity has a statistically significant negative effect on crime and arrest rates, and that hospital capacity affects crime and arrest rates in part, through its impact on homelessness. In addition, I find no crime‐reducing effect of private and general psychiatric hospital capacity.

Competencies of the consultation-liaison psychiatrist: A formulation from the general hospital section of the Dutch psychiatric association

Medical expert ! Demonstrate diagnostic and therapeutic skills in the ethical and effective care for patients with comorbid psychiatric and physical illness or with psychosomatic disorders ! Clinically apply the biopsychosocial model ! Access and apply relevant information in order to optimize clinical decision making with regard to both psychiatric and physical disease ! Indicate for and perform therapeutic interventions like pharmacotherapy, different types of psychotherapy, and electroconvulsive therapy in patients with medical comorbidity Communicator ! Establish a therapeutic relationship with patients and their families and a professional relationship with other medical specialists, nurses and other disciplines involved in As is the case in several other countries, medical training in the Netherlands has been subject to revision. The Central College of Medical Specialties, the training college of the Royal Dutch Medical Association, has formulated seven general competencies of the medical specialist along the lines of CanMEDS [1]. By defining these competencies (which in some way means making the implicit explicit), it becomes possible to formulate and develop more specific training programs that make competencies testable. Holding physicians accountable for their competence is not a new idea, but having uniform standards by which to assess such competence is [2]. In 1996, the Dutch Psychiatric Association (DPA or NVvP) published the bPsychiatrist’s Profile Q, a report that describes the knowledge and skills necessary to practice the profession in the various fields in which the psychiatrist can work [3]. This year, we will see the publication of a new edition that makes use of the CanMEDS format. General hospital psychiatry (including both consultationliaison activities and the work on the psychiatry unit) is not classed as a subspecialty in the Netherlands. However, as it is more and more recognized as an important bridge between psychiatry and general medicine, the general hospital section of the DPA sees the revision of the training curriculum as an opportunity to formulate the required competencies of a general hospital psychiatrist along the framework of the CanMEDS. The formulated ’essential roles and key competencies of general hospital psychiatrists’

Psychosomatic psychiatry: A Spanish proposal for a new dimension

Psychosomatic Medicine has undergone important evolutionary changes throughout its history, from its flowering in the 20th century up to the present. Two important reasons have determined this evolution. The first one has to do with the movement out of the focus in illnesses such as the bholy seven,Q illnesses with histological lesions once believed to have a psychogenic origin [1]. The knowledge about biological, ethiopathogenic mechanisms involved and effective treatment in these illnesses has improved considerably; on the contrary, psychogenic theories have been criticized on the basis of insufficient evidence. The second reason is the increasing demand for psychiatry to care for mental disorders in medical patients. Psychiatric disturbances are common in medical patients. On the other hand, the sharp increase in all aspects of medical practice, including prevention, diagnosis, and treatment, has generalized health care. Diagnostic and therapeutic techniques have dramatically improved life expectancy, and present-day prospects for recovery from illness would have been considered to be fantastic only a few years ago. However, extreme situations arise as a result of the new developments and the ethical problems they give rise to, which constantly threaten the psychological balance of the individual. The probability of needing psychiatric help when suffering somatic illnesses has increased significantly. A conservative estimate by the European Consultation-Liaison Workgroup for General Hospital Psychiatric and Psychosomatics [2] considers that approximately 10% of the patients admitted to a general hospital require consultation with a psychiatrist.