The evolving academic health center: challenges and opportunities for psychiatry.

Objective: Regardless of the outcome of current efforts at healthcare reform, the resources that academic health centers need-to provide care for increasingly complex patient populations, support clinical innovation, grow the clinical enterprise, and carry out their research and teaching missions-are in jeopardy. This article examines the value proposition for psychiatry.

Method: The authors describe areas where academic departments of psychiatry have opportunities to help shape the future of academic health centers in a rapidly-changing healthcare environment and share their experience in leadership roles in academic psychiatry and in consulting to academic health center leaders.

Can quality survive continued downward price pressures? Panel discussion.

The following is a transcript, edited for publication, of a remarkable presentation at the Behavioral Healthcare Quality and Accountability Summit in June 1997 held in Bloomington, Minnesota. The original session consisted of four talks, but since we were unable to obtain permission from one of the participants, J. Rock Johnson, J.

The impact of preadmission approval and continued stay review on hospital stay and outcome among children and adolescents.

Managed care has emerged as the centerpiece of the health care industry's efforts to control costs and ensure appropriate use of hospital services. This study assesses the impact of managed care by preadmission approval and/or continued stay review on length of psychiatric hospitalization and clinical outcome of children and adolescents. The sample included 277 cases hospitalized in nine psychiatric specialty hospitals in 1990.

Urinary MHPG and clinical symptoms in patients with unipolar depression.

The relationship between levels of urinary 3-methoxy-4-hydroxyphenylglycol (MHPG) and symptom scores on the Hamilton Rating Scale for Depression was examined in 31 patients with unipolar depression. Patients with either low MHPG or high MHPG showed significant sleep disturbance in the form of early morning awakening. Patients with mid-range or high MHPG showed decreased work and activities.

Personality disorders in cocaine dependence.

To assess the relationship between cocaine dependence and personality disorders, we administered the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) to 50 patients who were hospitalized for cocaine dependence. We modified the SCID-II so that patients were asked to indicate whether personality traits (if present) occurred during periods of drug use, abstinence, or both. Thirty-seven patients (74%) received at least one axis II diagnosis; 69% of these diagnoses were present both during periods of drug use and abstinence.

Case-based reimbursement for psychiatric hospital care.

A fixed-prepayment system (case-based reimbursement) for patients initially requiring hospital-level care was evaluated for one year through an arrangement between a private nonprofit psychiatric hospital and a self-insured company desiring to provide psychiatric services to its employees. This clinical and financial experiment offered a means of containing costs while monitoring quality of care. A two-group, case-control study was undertaken of treatment outcomes at discharge, patient satisfaction with hospital care, and service use and costs during the program's first year.

Psychopharmacological screening criteria. APA Committee on Research on Psychiatric Treatments.

This chapter includes a revision of psychopharmacological screening criteria originally developed in 1977-78 by the American Psychiatric Association (APA) and the National Institute of Mental Health (NIMH). This recent revision by the APA Committee on Research on Psychiatric Treatments provides criteria that are of considerable help in carrying out drug usage evaluations. Also included are useful suggestions for medical record documentation of specific classes of drugs, as well as for identification of adverse drug reactions.

Learned helplessness and urinary MHPG levels in unipolar depression.

Objective: Studies of the learned helplessness paradigm in laboratory animals show increased central noradrenergic activity following exposure to uncontrollable stressors. In clinical studies, depressed patients as a group report higher perceptions of helplessness and powerlessness. The authors examined the relationship between perceptions of powerlessness and noradrenergic activity in depressed patients.

Methodological considerations in the diagnosis of coexisting psychiatric disorders in substance abusers.

The authors reviewed the diagnostic methodology in 14 studies that examined the prevalence of coexisting psychiatric disorders in substance abusers. There was widespread variation among the studies in the timing of patient interviews, the nature of the interviews themselves, and abstinence criteria required before another psychiatric disorder could be diagnosed. These differences were reflected in some of the study results.

Eating disorders in hospitalized substance abusers.

Among 386 consecutive patients hospitalized for substance abuse, 15% of 143 women had a lifetime diagnosis of anorexia or bulimia nervosa, compared to only 1% of 243 men. Women with eating disorders had significantly higher rates of stimulant abuse and lower rates of opioid abuse than women without eating disorders.

Drug abuse as self-medication for depression: an empirical study.

The authors empirically studied the self-medication hypothesis of drug abuse by examining drug effects and motivation for drug use in 494 hospitalized drug abusers. Most patients reported that they used drugs in response to depressive symptoms and experienced mood elevation, regardless of their drug of choice. Drug use to relieve depressive symptoms was far more likely in men if they had major depression, but was equally common in women with and without major depression.

Why study treatment outcome?

Concern about the spiraling cost of mental health care has increased the need for reliable data about the outcomes of such care. Treatment outcome studies, although difficult to design and carry out, are essential in demonstrating the efficacy of psychiatric treatment, rationalizing clinical decision making, and encouraging public support for the availability of appropriate, cost-effective care for the mentally ill. Ideally, outcome studies should focus not only on clinical symptomatology but also on patients' social, interpersonal, and occupational adjustment as well as on factors that, taken together, shape the quality of life.

Biological measures and cellular immunological function in depressed psychiatric inpatients.

Thirty depressed psychiatric inpatients, including 18 with a diagnosis of major depression, and 25 hospital staff controls were compared with respect to cellular immune function--that is, mitogen responsiveness to concanavalin A (con A), phytohemagglutinin (PHA), and pokeweed mitogen (PWM); natural killer cell (NK) activity; and T cell subsets, including helper/inducer T cells (CD4) and suppressor/cytotoxic cells (CD8). Only physically healthy subjects, who had not used psychoactive medications (except for low dose benzodiazepines) or other medications known to affect the immune system for at least 14 days, were included. Paired comparisons of the immune measures of patients with a DSM-III diagnosis of major depression (n = 18) with their controls demonstrated a statistically significant reduction of the patients' con A response.

Psychopathology in drug abusers and their families.

Demographic, clinical, and family pedigree data obtained on 350 hospitalized drug-dependent patients showed that 52% also met DSM-III criteria for alcohol abuse or dependence, while 37% met DSM-III criteria for a concurrent axis I psychiatric disorder other than substance abuse. Cyclothymic disorder was significantly more common among cocaine abusers, while generalized anxiety disorder and panic disorder were more common among sedative-hypnotic abusers. Data on 1,478 first-degree relatives revealed that the prevalence of alcoholism and affective disorder was highly correlated with the occurrence of similar psychopathology in the probands.

Underdiagnosis of alcohol dependence in psychiatric inpatients.

Alcoholism is prevalent among psychiatric inpatients, and accurately diagnosing alcohol problems is a critical step in treatment planning. The authors diagnosed alcohol dependence in 35 psychiatric inpatients by blind review of interview protocols and hospital records. They then examined the frequency with which admitting and attending clinicians diagnosed alcohol abuse and dependence in these patients.

Tricyclic antidepressants in the treatment of alcoholism and drug abuse.

Although the frequent coexistence of substance abuse and depression is widely recognized, studies assessing the efficacy of tricyclic antidepressants in patients who abuse alcohol and/or drugs have been problematic because of controversies about how to diagnose depression in this population, failure to measure plasma antidepressant levels, and inconsistent treatment outcome measures. Some studies have, however, demonstrated the effective use of specific tricyclic antidepressants in selected subgroups of substance abusers; for example, desipramine may facilitate initiation of cocaine abstinence, and doxepin may benefit certain opioid addicts. Although imipramine has shown only equivocal success in the treatment of alcoholics, preliminary studies of serotonin uptake inhibitors show some promise in this population.

Diagnosing major depression in cocaine abusers: the use of depression rating scales.

This study compared the sensitivity and specificity of three rating scales in detecting major depression in 149 hospitalized cocaine abusers. Patients were administered the Beck Depression Inventory (BDI), the Hamilton Rating Scale for Depression, and the Symptom Checklist-90 at admission and at 2 weeks and 4 weeks of hospitalization. The admission BDI score offered the best combination of sensitivity and specificity.

A comparison of male and female cocaine abusers.

Little has been written about the differences between male and female cocaine abusers. We therefore compared sociodemographic characteristics, reasons for cocaine use, drug effects, depressive symptoms, and psychiatric diagnoses in 95 men and 34 women hospitalized for cocaine abuse. Men were more likely to be employed, to hold higher status jobs, and to be self-supporting.

Psychopathology in cocaine abusers. Changing trends.

The authors studied a group of 149 hospitalized cocaine abusers as a follow-up to previous research performed in 1980-82, which had revealed a high prevalence of affective disorder in cocaine abusers. The authors hypothesized that the changing epidemiology of cocaine abuse since that time may have been accompanied by changes in the characteristics of patients seeking treatment for dependence on the drug. The cocaine abusers were compared with 293 other drug abusers to see whether clinical changes over time were specific to individuals abusing cocaine.

A comparison of alcoholic and nonalcoholic drug abusers.

A group of 329 hospitalized drug abusers were evaluated for a current or past diagnosis of alcoholism. The alcoholic drug-dependent patients (n = 169, 51.4%) were then compared with the nonalcoholic patients (n = 160, 48.