Preface

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This issue is devoted to psychiatric care of the medically ill. The major US organization dedicated to this care is the Academy of Psychosomatic Medicine. The articles in this issue represent authors and topics selected from among the best papers and presentations at the annual meeting of the academy in November 2000, expanded and updated for this special issue of Psychiatric Clinics of North America.

Psychiatric disorders occur very frequently in the medically ill, with about 30% to 50% of patients with serious medical illnesses suffering from a comorbid psychiatric disorder. Mood disorders, anxiety disorders, delirium, dementia, and substance abuse are most common. Psychopathology is especially frequent in patients with complex medical illnesses such as HIV, end-stage renal disease, organ transplantation, cancer, and traumatic brain injury. Consequently, patients in general hospitals have the highest rate of psychiatric disorders, compared with community samples or primary care patients. Compared with community residents, hospitalized patients have major depression and substance abuse two to three times as often and somatization disorder 10 times as often. Medically ill patients with psychopathology also may present to primary care and specialists' offices, nursing homes, home health care, and other health care environments. Extensive research has documented the frequency and nature of the specific psychiatric morbidities found in specific medical disease patient populations, the serious consequences of the psychiatric morbidity, and the benefits to patients and the health care system of having psychiatric care provided to these patients by expert psychiatrists.

Why are psychiatric disorders so frequent in medical settings? Some represent reactions to the stresses of illness and treatment, while others are a direct physiologic consequence of the illness (e.g., delirium) or complications of treatment (e.g., steroid psychosis). Psychiatric disorders may be coincident with but etiologically unrelated to a medical disorder. Still, each complicates the management of the other. Schizophrenia may make it very hard for a patient to follow a diabetic regimen, while the diabetic's glucose intolerance and hyperlipidemia complicate the choice of a neuroleptic. There are also frequent psychophysiological (psychosomatic) inter-relationships between disorders. For example, depression and coronary disease commonly occur together, and each appears to be a risk factor for the development of, or aggravation of, the other. Explanatory pathophysiologic mechanisms are being worked out. Another reason for common medical-psychiatric comorbidity is that there are a number of commonly shared risk factors for the development of a variety of psychiatric and medical disorders (e.g., smoking or low socioeconomic status). Finally, patients who have comorbid medical and mental disorders are “high utilizers” of medical services compared with patients with only medical disorders, and thus the former present disproportionately for diagnosis and treatment in medical settings.

The higher concentration of patients with psychiatric disorders in medical settings provides a critical opportunity to intervene in patients who might otherwise go undiagnosed and untreated. Failure to identify, evaluate, diagnose, treat, or achieve palliation results in significant adverse outcomes, including an increase in psychological and medical morbidity, mortality, and higher health care utilization and costs. Yet failure to treat occurs all too frequently.

The presence of significant medical illness complicates the diagnosis of psychopathology. It is often difficult to determine if the vegetative symptoms of depression or the somatic symptoms of anxiety are evidence of a psychiatric disorder or symptoms of medical illness (or both). Physical illness can mimic psychiatric disorders, and some psychopathology presents as a semblance of medical illness (the somatoform disorders). In this issue, Drs. Schneider, Robinson, and Levenson review three infectious diseases with prominent neuropsychiatric manifestations that present diagnostic challenges: neurocysticercosis, Lyme disease, and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection. Drs. Bostwick and Philbrick review the electroencephalogram, which can be helpful in discriminating between etiologies of neuropsychiatric symptoms.

As noted, psychopathology is especially common in patients with complex medical illnesses, and this can have important effects on diagnosis, disease course, management, treatment, prognosis, and outcome. In this issue, contributors focus on psychiatric care of patients recovering from car accidents (Dr. Mayou), traumatic brain injury (Drs. Rao and Lyketsos), refractory chronic pain (Drs. Clark and Cox), pulmonary disease (Dr. Coffman), and burns (Dr. Ilechukwu). Psychiatric treatment in medically ill patients is more difficult because of the risks posed by patients' medical comorbidities, the averse effects of medical and surgical treatments received, and drug-drug interactions. In this issue, Drs. Robinson and Qaqish review the complexities of psychopharmacology in patients with HIV. Drs. Rasmussen, Rummans, and Richardson review the use of electroconvulsive therapy in the medically ill. The illumination they provide should help expand the use of effective but underutilized treatment modalities in the medically ill.

Psychiatrists who care for the medically ill are at the frontiers of medicine. Their clinical expertise and research contributions have had important implications influencing new medical and surgical treatments. One example has been the changes in policy and practice regarding liver transplantation for alcoholic patients, reviewed by Drs. DiMartini, Weinrieb, and Fireman. Other frontiers addressed in this issue are the rapidly increasing use of herbal remedies and nonherbal supplements (Drs. Crone and Gabriel) and “designer drugs” (Dr. Bialer).

The authors hope you find this rich buffet of topics in psychiatric care of the medically ill as filling and fulfilling as they did. Bon appetit.