Past Psychiatric Hospitalization Research Articles

Clinical and sociodemographic characteristics of patients with epilepsy attended at a regional reference psychiatric emergency unit

ObjectiveEpilepsy is one of the most prevalent chronic neurological diseases, presenting a high frequency of psychiatric disorders (PD). This study sought to evaluate the clinical and sociodemographic profile of patients with epilepsy (PWE) attended at a regional reference psychiatric emergency unit. MethodsA retrospective, cross-sectional, and descriptive observational study was conducted utilizing a patient record database of individuals with epilepsy who were attended in a regional reference psychiatric emergency unit between January 2018 and August 2022. ResultsOut of the 31,800 psychiatric emergency visits, 260 (0.8 %) were of patients with epilepsy (ICD-10: G40). The majority were males (63.5 %) with a mean age of 42.11±15.39 years, single marital status (154; 59.25 %) and elementary education (75; 28.9 %). Most of them (203; 78.1 %) presented at least one psychiatric comorbidity at the emergency visit, but 109 (41.9 %) were not receiving any psychiatric follow-up. A total of 106 patients (40.8 %) had experienced at least one past psychiatric hospitalization. ConclusionsThe occurrence of PD is highly prevalent in PWE, and probably with a high frequency of psychiatric emergencies occurring among them. Further studies are needed to assess such patient profile, particularly involving data from psychiatric emergency units.

A-254 Psychiatric History and Cognitive Impairment in a Subpopulation of Older Adults in a Psychiatric Hospital

Abstract Objective: The purpose of this study is to characterize the neuropsychological (NP) profile of an Older Adult Unit (OAU) subpopulation and determine whether past psychiatric hospitalizations (PH) and longstanding psychiatric history (LPH) are associated with severity of cognitive impairment. Method: Records were reviewed for a sample of patients admitted to the OAU in a private psychiatric hospital in the Midwest who were referred for a neuropsychological consult in 2018-2019. Only participants diagnosed with a neurocognitive disorder (NCD) were included (74% major, 26% mild). The final sample (N = 72) was 65% female, 82% Caucasian, with a mean age and education level of 75 years (SD =8.23) and 12.8 years (SD = 2.36), respectively. Thirty-seven percent had at least one prior PH. Forty-four percent of the sample had LPH. Participants completed comprehensive NP testing. Results: A chi-square test of independence with Bonferroni correction was performed to examine the relationships between prior PH and LPH with severity of cognitive impairment (mild versus major NCD). Severity of cognitive impairment was not significantly associated with either prior PH, X2 (1, N = 72) = .005, p = 0.945, or LPH, X2 (1, N = 72) = .604, p = 0.437. Conclusions: Unexpectedly, neither prior PH nor LPH were associated with severity of cognitive impairment. This suggests that prior psychiatric history may be predictive of presence but not severity of cognitive impairment. Possible explanations for these findings include study/sample limitations, unexplored confounding variables, and possible test limitations. Future studies should include a larger sample with a control group.

Socio-Demographic and Clinical Characteristics of Psychiatric Patients Who Have Committed Suicide: Analysis of Bulgarian Regional Suicidal Registry for 10 Years.

Introduction: Suicide is a major public health problem but factors determining suicide risk are still unclear. Studies in this field in Bulgaria are limited, especially on a regional level.Methods: By a cross-sectional design, we accessed the medical records of all psychiatric patients committed suicide over a 10-year period (2009–2018) in one major administrative region of Bulgaria. A statistical analysis was performed of the association between age of suicide as an indirect yet measurable expression of the underlying suicidal diathesis and a number of socio-demographic and clinical characteristics.Results: Seventy-seven of 281 suicides (28%) had psychiatric records. Most common diagnoses were mood disorders (44%), followed by schizophrenia (27%), anxiety disorders (10%), substance use disorders (9%) and organic conditions (8%). Male gender, single/divorced marital status, early illness onset, co-occurring substance misuse and lower educational attainment (for patients aged below 70) were significantly associated with earlier age of suicide whereas past suicide attempts and psychiatric hospitalizations, comorbid somatic conditions and unemployment showed insignificant association. Substantial proportion of patients (60%) had contacted psychiatric service in the year preceding suicide, with nearly half of these encounters being within 30 days of the accident.Conclusion: Severe mental disorders are major suicide risk factor with additional contribution of certain socio-demographic and illness-related characteristics. Monitoring for suicidality must be constant in chronic psychiatric patients. Registration of suicide cases in Bulgaria needs improvement in terms of information concerning mental health. More studies with larger samples and longitudinal design are needed to further elucidate distal and proximal suicide risk factors.

Estimating an individual-level deprivation index for HIV/HCV coinfected persons in Canada.

BackgroundHIV-HCV coinfected individuals are often more deprived than the general population. However, deprivation is difficult to measure, often relying on aggregate data which does not capture individual heterogeneity. We developed an individual-level deprivation index for HIV-HCV co-infected persons that encapsulated social, material, and lifestyle factors.MethodsWe estimated an individual-level deprivation index with data from the Canadian Coinfection Cohort, a national prospective cohort study. We used a predetermined process to select 9 out of 19 dichotomous variables at baseline visit to include in the deprivation model: income >$1500/month; education >high school; employment; identifying as gay or bisexual; Indigenous status; injection drug use in last 6 months; injection drug use ever; past incarceration, and past psychiatric hospitalization. We fitted an item response theory model with: severity parameters (how likely an item was reported), discriminatory parameters, (how well a variable distinguished index levels), and an individual parameter (the index). We considered two models: a simple one with no provincial variation and a hierarchical model by province. The Widely Applicable Information Criterion (WAIC) was used to compare the fitted models. To showcase a potential utility of the proposed index, we evaluated with logistic regression the association of the index with non-attendance to a second clinic visit (as a proxy for disengagement) and using WAIC compared it to a model containing all the individual parameters that compose the index as covariates.ResultsWe analyzed 1547 complete cases of 1842 enrolled participants. According to the WAIC the hierarchical model provided a better fit when compared to the model that does not consider the individual’s province. Values of the index were similarly distributed across the provinces. Overall, past incarceration, education, and unemployment had the highest discriminatory parameters. However, in each province different components of the index were associated with being deprived reflecting local epidemiology. For example, Saskatchewan had the highest severity parameter for Indigenous status while Quebec the lowest. For the secondary analysis, 457 (30%) failed to attend a second visit. A one-unit increase in the index was associated with 17% increased odds (95% credible interval, 2% to 34%) of not attending a second visit. The model with just the index performed better than the model with all the components as covariates in terms of WAIC.ConclusionWe estimated an individual-level deprivation index in the Canadian Coinfection cohort. The index identified deprivation profiles across different provinces. This index and the methodology used may be useful in studying health and treatment outcomes that are influenced by social disparities in co-infected Canadians. The methodological approach described can be used in other studies with similar characteristics.

Effect of Previous Electroconvulsive Therapy on Subsequent Response to Transcranial Magnetic Stimulation for Major Depressive Disorder

Patients with major depressive disorder (MDD) who received electroconvulsive therapy (ECT) often seek transcranial magnetic stimulation (TMS) therapy as a less invasive treatment option. How prior history of ECT and its responsiveness may affect TMS treatment outcomes for MDD is unclear. We aim to contribute evidence to this important clinical question. Retrospective naturalistic TMS treatment data from n = 257 MDD patients. Three sets of analyses were conducted: History of past exposure to ECT (n = 71, "+ECT" vs. n = 186 ECT-naïve, "-ECT") was examined as a potential predictor of TMS outcomes (measured by two self-report scales); A subset of n = 38 +ECT patients with adequate ECT trials in current depression episode were compared with -ECT patients blindly matched on clinical variables associated with TMS outcomes; for a subset with available data, TMS outcomes were explored in relation to positive/negative response to prior ECT. Compared to -ECT, +ECT patients more likely had past psychiatric hospitalizations (p < 0.01) and were more severely depressed at baseline (p = 0.07). Response (p = 0.07) and remission (p = 0.02) rates were higher in -ECT than +ECT groups on one scale. However, comparison between the subsets (n = 38 each) matched on confounding factors did not find history of ECT to be a significant independent predictor of TMS outcomes. Differential responsiveness to ECT and ECT treatment characteristics did not significantly impact TMS outcomes. Although limited by the retrospective nature of this analysis, the results suggest that history of the past ECT, regardless of responsiveness to ECT, may not independently portend differential TMS treatment outcomes.

Who is willing to participate in research? A screening model for an anxiety and depression trial in the epilepsy clinic

ObjectiveAnxiety and depression in epilepsy are prevalent, associated with poor outcomes, underrecognized, undertreated, and thus a key area of need for treatment research. The objective of this study was to assess factors associated with research participation among epilepsy clinic patients who screened positive for anxiety or depression. This was accomplished by characterizing clinical and psychiatric factors among patients seen in an epilepsy clinic and evaluating which factors were associated with consent for potential research participation, via a combined clinical and research screening model. MethodsIn a pragmatic trial of anxiety and depression treatment in epilepsy, individuals with a positive screen for anxiety and/or depression at a routine epilepsy clinic visit were invited to opt-in (via brief electronic consent) to further eligibility assessment for a randomized treatment study. Information on psychiatric symptoms and treatment characteristics were collected for dual clinical care and research screening purposes. Cross-sectional association of demographic, clinical, and psychiatric factors with opting-in to research was analyzed by multiple logistic regression. ResultsAmong N = 199 unique adults with a first positive screen for anxiety and/or depression among 786 total screening events, 154 (77.4%) opted-in to further potential research assessment. Higher depression scores and current treatment with an antidepressant were independently associated with opting-in to research (depression odds ratio (OR) = 1.13 per 1-point increase in Neurological Disorders Depression Inventory-Epilepsy (NDDI-E) score, p = 0.028, 95% confidence interval (CI): 1.01–1.26; antidepressant OR = 2.37, p = 0.041, CI: 1.04–5.41). Nearly half of the 199 individuals (43.7%) with anxiety and/or depression symptoms were already being treated with an antidepressant, and 46.7% were receiving neither antidepressant therapy nor mental health specialty care. One-quarter (24.1%) reported a past psychiatric hospitalization, yet only half of these individuals were receiving mental health specialty care. SignificanceOur results demonstrate a high willingness to participate in research using a brief electronic consent approach at a routine clinic visit. Adults with persistent anxiety or depression symptoms despite antidepressant therapy and those with higher depression scores were more willing to consider a randomized treatment study. This has implications for future study design, as individuals already on treatment or those with more severe symptoms are often excluded from traditional research designs. We also found a high burden of psychiatric disease and high prevalence of persistent symptoms despite ongoing antidepressant treatment.

Suicide Risk Among Holocaust Survivors Following Psychiatric Hospitalizations: A Historic Cohort Study

The association between Holocaust experience, suicide, and psychiatric hospitalization has not been unequivocally established. The aim of this study was to determine the risk of suicide among 3 Jewish groups with past or current psychiatric hospitalizations: Holocaust survivors (HS), survivors of pre-Holocaust persecution (early HS), and a comparison group of similar European background who did not experience Holocaust persecution. In a retrospective cohort study based on the Israel National Psychiatric Case Register (NPCR) and the database of causes of death, all suicides in the years 1981–2009 were found for HS (n = 16,406), early HS (n = 1,212) and a comparison group (n = 4,286). Age adjusted suicide rates were calculated for the 3 groups and a logistic regression model was built to assess the suicide risk, controlling for demographic and clinical variables. The number of completed suicides in the study period was: HS—233 (1.4%), early HS—34 (2.8%), and the comparison group—64 (1.5%). Age adjusted rates were 106.7 (95% CI 93.0–120.5) per 100,000 person-years for HS, 231.0 (95% CI 157.0–327.9) for early HS and 150.7 (95% CI 113.2–196.6) for comparisons. The regression models showed significantly higher risk for the early HS versus comparisons (multivariate model adjusted OR = 1.68, 95% CI 1.09–2.60), but not for the HS versus comparisons. These results may indicate higher resilience among the survivors of maximal adversity compared to others who experienced lesser persecution.

Neuropsychiatric Associations With Gender, Illness Duration, Work Disability, and Motor Subtype in a U.S. Functional Neurological Disorders Clinic Population.

The assessment of functional neurological disorders (FND) requires an interdisciplinary approach. The authors retrospectively reviewed charts for 100 outpatients with FND and used univariate and regression analyses to investigate neuropsychiatric associations with gender, illness duration, and work disability; secondary analyses evaluated for differences across motor FND subtypes. Men reported higher rates of cognitive complaints and functional weakness, whereas women endorsed increased past physical/sexual trauma. Number of self-reported medication allergies/sensitivities positively correlated with illness duration. Individuals with functional weakness compared with other motor FND subtypes exhibited lower rates of past psychiatric hospitalization and head trauma. This study supports the feasibility of integrating FND research.

Preliminary Predictors of Initial Attendance, Symptom Burden, and Motor Subtype in a US Functional Neurological Disorders Clinic Population.

Although many patients present with functional neurological symptoms (FNS), few US clinics offer specialized FNS care, and data on clinic attendees remain limited. We determined predictors of initial attendance, symptom burden, and FNS subtype in the first patients referred to our Functional Neurological Disorders Clinic for suspected FNS. We reviewed the charts of 62 consecutive patients (46 women, 16 men). Regression analyses investigated predictors of keeping the first scheduled clinic appointment. For the 49 patients who did keep that appointment, regression analyses examined neuropsychiatric factors associated with symptom burden and motor FNS subtypes. The odds of not keeping the first appointment were 10.4 times greater for patients referred from the emergency department than from other sources. The patients who kept their appointment reported a symptom burden that was significantly associated with a past FNS-related emergency department visit and a diagnosis of another medically unexplained somatic syndrome. The number of FNS findings on neurological examination also correlated with a history of an FNS-related emergency department visit. Patients with psychogenic non-epileptic seizures reported cognitive complaints and prior psychiatric hospitalizations significantly more often than did patients with other FNS. One fourth of all patients had two or more motor FNS. In our FNS cohort, patients were less likely to keep an initial clinic appointment if they were referred from the emergency department than from other sources. Patients with psychogenic non-epileptic seizures were more likely to report cognitive symptoms and past psychiatric hospitalizations than patients with other FNS.

MHealth for Schizophrenia: Patient Engagement With a Mobile Phone Intervention Following Hospital Discharge.

BackgroundmHealth interventions that use mobile phones as instruments for illness management are gaining popularity. Research examining mobile phone‒based mHealth programs for people with psychosis has shown that these approaches are feasible, acceptable, and clinically promising. However, most mHealth initiatives involving people with schizophrenia have spanned periods ranging from a few days to several weeks and have typically involved participants who were clinically stable.ObjectiveOur aim was to evaluate the viability of extended mHealth interventions for people with schizophrenia-spectrum disorders following hospital discharge. Specifically, we set out to examine the following: (1) Can individuals be engaged with a mobile phone intervention program during this high-risk period?, (2) Are age, gender, racial background, or hospitalization history associated with their engagement or persistence in using a mobile phone intervention over time?, and (3) Does engagement differ by characteristics of the mHealth intervention itself (ie, pre-programmed vs on-demand functions)?MethodsWe examined mHealth intervention use and demographic and clinical predictors of engagement in 342 individuals with schizophrenia-spectrum disorders who were given the FOCUS mobile phone intervention as part of a technology-assisted relapse prevention program during the 6-month high-risk period following hospitalization.ResultsOn average, participants engaged with FOCUS for 82% of the weeks they had the mobile phone. People who used FOCUS more often continued using it over longer periods: 44% used the intervention over 5-6 months, on average 4.3 days a week. Gender, race, age, and number of past psychiatric hospitalizations were associated with engagement. Females used FOCUS on average 0.4 more days a week than males. White participants engaged on average 0.7 days more a week than African-Americans and responded to prompts on 0.7 days more a week than Hispanic participants. Younger participants (age 18-29) had 0.4 fewer days of on-demand use a week than individuals who were 30-45 years old and 0.5 fewer days a week than older participants (age 46-60). Participants with fewer past hospitalizations (1-6) engaged on average 0.2 more days a week than those with seven or more. mHealth program functions were associated with engagement. Participants responded to prompts more often than they self-initiated on-demand tools, but both FOCUS functions were used regularly. Both types of intervention use declined over time (on-demand use had a steeper decline). Although mHealth use declined, the majority of individuals used both on-demand and system-prompted functions regularly throughout their participation. Therefore, neither function is extraneous.ConclusionsThe findings demonstrated that individuals with schizophrenia-spectrum disorders can actively engage with a clinically supported mobile phone intervention for up to 6 months following hospital discharge. mHealth may be useful in reaching a clinical population that is typically difficult to engage during high-risk periods.

Illness-course modulates suicidality-related prefrontal gray matter reduction in women with bipolar disorder.

Explore interrelationships between suicide attempt history (Objective 1) or suicide attempt severity (Objective 2) with prefrontal cortex gray matter (PFCGM ) volume and illness-course in patients with bipolar disorder (BD). Ninety-three women with BD-I or -II diagnosis (51 with and 42 without suicide attempt history) underwent structural MRI and filled out questionnaires. Measured were GM volumes of 11 PFC regions, BD illness-course, and attempt history and severity. Effects were examined with repeated measures GLM or logit analyses. Objective 1: Attempt history was associated with increased trait impulsivity and aggression, and higher prevalence of BD-I, past drug use disorder, and past psychiatric hospitalization. PFCGM volume was lower in patients with than without attempt history in those with past psychiatric hospitalization. PFCGM volume was higher in patients with than without attempt history in those without hospitalization. Higher trait aggression predicted attempt history. Objective 2: Increased frontal pole volume and younger age at first hospitalization predicted many suicide attempts. Attempt history in patients with BD related to PFCGM volume reduction or increase. Volume modulation by psychiatric hospitalization could reflect effects of illness-course or care. Attempt severity was not related to volume reduction. Research on suicidality-brain relationships should include illness-course and attempt severity measures.

Juvenile bipolar disorder and suicidality: a review of the last 10 years of literature

Although children and adolescents with bipolar disorder (BD) are at elevated risk for suicide, little research to date has been conducted on suicidality in this population. The purpose of this descriptive review of the past 10years of scientific literature on suicidality in youths with BD was to identify the risk and protective factors associated with this phenomenon, and to discuss the implications for research and clinical practice. Searches on Medline and PsycINFO databases for the period from early 2002 to mid-2012 yielded 16 relevant articles, which were subsequently explored using an analysis grid. Note that the authors employed a consensus analysis approach at all stages of the review. Four primary categories of risk factors for suicidality in youths with BD were identified: demographic (age and gender), clinical (depression, mixed state or mixed features specifier, mania, anxiety disorders, psychotic symptoms, and substance abuse), psychological (cyclothymic temperament, hopelessness, poor anger management, low self-esteem, external locus of control, impulsivity and aggressiveness, previous suicide attempts, and history of suicide ideation, non-suicidal self-injurious behaviors and past psychiatric hospitalization), and family/social (family history of attempted suicide, family history of depression, low quality of life, poor family functioning, stressful life events, physical/sexual abuse, and social withdrawal). Youths with BD who experienced more complex symptomatic profiles were at greater risk of suicidality. Few protective factors associated with suicidality have been studied among youths with BD. One protective factor was found in this descriptive literature review: the positive effects of dialectical behavior therapy. This article allows a better appreciation of the risk and protective factors associated with suicidality among youth with BD. Greater awareness of risk factors is the first step in suicide prevention.

A 21-Year-Old Woman Who Had a Complicated Birth

The patient was a 21-yearold woman who had a complicated birth. When she was born, she had aspirated meconium, had apnea, and had an 8-day stay in the neonatal intensive care unit (NICU). At the time of her admission, the woman lived with her parents and her 18-year-old sister in a home located in the same town where she graduated from high school with academic success. At admission, she was entering her senior year at a local college, where she had previously made the dean’s list. She denied a history of substance or alcohol use and was noted by her family to be a “rule follower” who had trouble “fitting in.” Her parents described her as shy and polite with strangers and acquaintances, but they said she was stubborn at home. Over the past few years, her parents said she preferred to spend much of her free time alone on the Internet or doing schoolwork. The patient had a self-reported history of depression since she was 13 years old, but she denied past psychiatric hospitalization or treatment. When she was 17 years old, she twice impulsively expressed suicidal ideation to her parents, but her parents said she quickly retracted these statements. She reported a history of visual hallucinations, consisting of bugs, for “as long as I can remember.” Two years before her psychotic episode and hospitalization, an EEG showed mild diffuse slowing. Magnetic resonance imaging (MRI) of the brain showed right parieto-temporal and periventricular encephalomalacia. The patient’s family history was significant for bipolar disorder in her mother, who was recently diagnosed, and her maternal aunt. According to the family, the patient had demonstrated increased frustration and sadness in the month leading up to her admission. In one instance, she returned home extremely agitated after attending a barbecue with friends, declaring that “no one understands me.” The patient often was observed staring at her computer, completely unaware of her surroundings for minutes at a time, then suddenly becoming attentive again without an understanding of time having passed. She experienced insomnia but denied

Validation of Brief Screening Tools for Mental Disorders Among New Zealand Prisoners

Validation of Brief Screening Tools for Mental Disorders Among New Zealand Prisoners

Mental health services utilization and driving violations

Objective. The objective of this study was to determine whether there is a relationship between the past utilization of four mental health services (i.e. ever been seen by a psychiatrist, ever been in a psychiatric hospital, ever been in counseling, ever been on psychotropic medication) and different types of driving citations during one's lifetime. Methods. Using a consecutive, cross-sectional, primary care sample, we surveyed participants about their past use of four mental health services and lifetime incidence of 29 different types of driving citations (charges, not convictions). Results. The total number of different types of moving violations was statistically significantly related to a history of psychiatric hospitalization. The total number of different types of non-moving violations was statistically significantly related to all mental health services variables. Conclusions. In this study, general non-specific queries about the past utilization of mental health services were correlated with both moving violations (past psychiatric hospitalization) and non-moving violations (all mental health services variables). These findings suggest that patients who have received mental health treatment are at a higher risk for being cited for driving violations than those who have not received mental health treatment. However, among the mental health variables under study, only past psychiatric hospitalization was associated with moving violations.

Trauma as a Predictive Indicator of Clinical Outcome in Residential Treatment

The present study was conducted to identify predictors of residential treatment outcome for youth. Data were collected and analyzed on multiple variables including each subject's psychiatric diagnoses, previous treatment attempts and success or failure in these respective settings, length of stay in prior treatment settings, past psychiatric hospitalizations, medication usage, trauma history, short-term and long-term treatment goals, and presenting symptomatology at admission to residential treatment. For this sample, analysis of outcomes data indicated that exposure to a variety of types of trauma was the single greatest predictor of improvement or deterioration in residential treatment.

Counseling Center-Based Tele-Mental Health for Students at a Rural University

Students attending rural academic institutions often have no immediate access to psychiatrists to supplement on-site Counseling Center (CC) services. Because the Medical College of Georgia (MCG) could not cost-effectively provide on-site psychiatry services to Georgia Southern University (GSU) students, the two institutions explored telehealth services delivered by supervised Psychiatry residents using Web-based videoconferencing on MCGs virtual private network. GSU counselors completed client severity rating forms. CC clients in ongoing therapy who were judged to be in need of psychiatric services were referred to the Tele-clinic (TC). CC counselors referred the most challenged students to TC according to total distress score on intake, clinician intake assessment of client difficulty, and client need for medications. After seeing the clients in TC, MCG residents also completed GSU CC client severity rating forms. Post-intake and satisfaction surveys already in use at the GSU CC were completed both by CC clients not in TC and by CC clients jointly enrolled in TC. TC and CC populations were compared by gender, race, past mental health treatment, past psychiatric hospitalization, and past and current use of psychotropic drugs. Telepsychiatry conducted using low bandwidth videoconferencing successfully supplemented GSU CC mental healthcare, especially for clients with the most serious problems, and did so without travel from campus and within the milieu of daily student life. Cost-effective telepsychiatry services can successfully supplement management of students with mental health issues who attend rural, smaller, and/or resource-challenged academic institutions.

Lithium-Induced Rash

Sir: Lithium has been used as a mood stabilizer for decades and has been approved by the U.S. Food and Drug Administration for acute and maintenance therapy of mania in bipolar disorder. The Physicians' Desk Reference lists generalized pruritus with or without rash as one of the dermatologic side effects of lithium.1 We present an interesting case of maculopapular rash that we believe was induced with lithium. Case report. Ms. A, a 60-year-old woman with a past psychiatric history of bipolar disorder, was brought to the emergency room in 2005 by her family for some odd behaviors. The family described a 2-week history of spending sprees, staying up all night, talking excessively, and making inappropriate phone calls. She called her former employers and was verbally abusive to them, which resulted in a restraining order being issued against her. A thorough medical work-up in the emergency room did not reveal any significant findings. Her past medical history was significant for coronary bypass graft, end stage renal disease requiring dialysis, and gastritis. Her current medications were captopril, omeprazole, atrovastatin, aspirin, spirono-lactone, amiodarone, and cetrizine. She was found to have pressured speech with a circumstantial thought process without any psychosis or cognitive impairment. She was later transferred to the psychiatric floor for stabilization. The patient had a history of bipolar disorder with 4 past psychiatric hospitalizations, the last being 6 years ago. She had been on divalproex and lithium in the past with no adverse effects, but noncompliance has been an ongoing issue in her case. There had been no psychiatric follow-up for the last 5 years. A diagnosis of bipolar disorder, most recent episode manic, was made using the DSM-IV diagnostic criteria, and she was started on lithium 300 mg at bedtime and que-tiapine 25 mg at bedtime on an as-needed basis for sleep. Within a few days a significant symptomatic improvement was noticed. On the sixth day after initiation of lithium, she was found to have a red maculopapular rash about 5 cm × 3 cm in size over the left pretibial area. There were no complaints of itching or any signs of systemic infection. Her lithium level a day before was 0.5 mEq/L. Her lithium was withheld, resulting in a fading of her rash over the next 2 days. Unfortunately, she left the hospital against medical advice and went to the home of her daughter, who convinced us that the patient would follow up with outpatient psychiatry within the next few days. It has been reported that women are at increased risk of cutaneous lesions when treated with lithium, usually within the first year of its initiation.2 In our case, the temporal association of the onset of the rash within a week of the initiation of lithium and its fading within 2 days of its discontinuation points to a causal relationship. Although the exact mechanism is unclear, it has been proposed that inhibition of adenylate cyclase/cyclic AMP systems induced by lithium could be responsible for the cutaneous conditions.2 Other lithium-induced skin conditions include psoriasis, acne, folliculitis, exfoliative dermatitis, seborrheic dermatitis, and herpetiform dermatitis. The prevalence rate of lithium-induced cutaneous reaction has been reported to be 34% in one study2 and 45% in another.3 Further investigation regarding cutaneous lesions associated with lithium therapy is warranted as this distressing side effect could adversely affect the medication compliance.

General Practitioners' opinions on their practice in mental health and their collaboration with mental health professionals.

BackgroundCommon mental health problems are mainly treated in primary care settings and collaboration with mental health services is needed. Prior to re-organisation of the mental health care offer in a geographical area, a study was organized: 1) to evaluate GPs' opinions on their day-to-day practice with Patients with Mental Health Problems (PMHP) and on relationships with Mental Health Professionals (MHPro); 2) to identify factors associated with perceived need for collaboration with MHPro and with actual collaboration.MethodsAll GPs in the South Yvelines area in France (n = 492) were informed of the implementation of a local mental health program. GPs interested in taking part (n = 180) were invited to complete a satisfaction questionnaire on their practice in the field of Mental Health and to include prospectively all PMHP consultants over an 8-day period (n = 1519). For each PMHP, data was collected on demographic and clinical profile, and on needs (met v. unmet) for collaboration with MHPro.ResultsA majority of GPs rated PMHP as requiring more care (83.4%), more time (92.3%), more frequent consultations (64.0%) and as being more difficult to refer (87.7%) than other patients. A minority of GPs had a satisfactory relationship with private psychiatrists (49.5%), public psychiatrists (35%) and social workers (27.8%). 53.9% had a less satisfactory relationship with MHPro than with other physicians.Needs for collaboration with a MHPro were more often felt in caring for PMHP who were young, not in employment, with mental health problems lasting for more than one year, with a history of psychiatric hospitalization, and showing reluctance to talk of psychological problems and to consult a MHPro.Needs for collaboration were more often met among PMHP with past psychiatric consultation or hospitalization and when the patient was not reluctant to consult a MHPro. Where needs were not met, GP would opt for the classic procedure of mental health referral for only 31.3% of their PMHP.ConclusionGPs need targeted collaboration with MHPro to support their management of PMHP, whom they are willing to care for without systematic referral to specialists as the major therapeutic option.

Perceived Reasons for Loss of Housing and Continued Homelessness Among Homeless Persons With Mental Illness

The objective of this study was to examine the reasons for the most recent loss of housing and for continued homelessness as perceived by homeless persons with mental illness. A total of 2,974 currently homeless participants in the 1996 National Survey of Homeless Assistance Providers and Clients (NSHAPC) were asked about the reasons for their most recent loss of housing and continued homelessness. The responses of participants who had mental illness, defined both broadly and narrowly, were compared with responses of those who were not mentally ill. The broad definition of mental illness was based on a set of criteria proposed by NSHAPC investigators. The narrow definition included past psychiatric hospitalization in addition to the NSHAPC criteria. A total of 1,620 participants (56 percent) met the broad definition of mental illness, and 639 (22 percent) met the narrow definition; 1,345 participants (44 percent) did not meet any of these criteria and were categorized as not having a mental illness. Few differences in reasons for the most recent loss of housing were noted between the participants with and without mental illness. Both groups attributed their continued homelessness mostly to insufficient income, unemployment, and lack of suitable housing. Homeless persons with mental illness mostly report the same reasons for loss of housing and continued homelessness as those who do not have a mental illness. This finding supports the view that structural solutions, such as wider availability of low-cost housing and income support, would reduce the risk of homelessness among persons with mental illness, as among other vulnerable social groups.