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Care of the Suicidal Patient

Overview Suicide, or intentional self-harm with the intent of causing death, is the 11th leading cause of death in the United States, accounting for more than 40,000 deaths each year. Non-lethal self-inflicted injuries are even more prevalent, accounting for nearly 800,000 Emergency Department (ED) visits per year and reflecting the high ratio of suicide attempts to completed suicides. Psychiatric disorders, as the most powerful risk factor…

Difficult Patients

Overview The medical equivalent of war is the care of the difficult patient. Doctors soldier steadily on through all kinds of clinical chores, arduous schedules, and “administrivia,” but when they get to the types of patients variously called “obnoxious,” “needy,” “crocky,” “malignant,” and even “hateful,” they fight the worst battles of their careers, become prone to clinical blunders, mess up their personal lives, violate boundaries, and…

Complementary Medicine and Natural Medications

Overview Complementary and alternative medical (CAM) therapies constitute a diverse spectrum of practices and beliefs in current medical practice. The National Institutes of Health has defined CAM as “healthcare practices outside the realm of conventional medicine, which are yet to be validated using scientific methods.” The term natural medications refers to medications derived from natural products that are not approved by the U.S. Food and Drug…

Chronic Disease and Unhealthy Habits: Behavioral Management

Overview Lifestyle choices are associated with the development of chronic non-communicable diseases (NCDs). Centuries ago, Hippocrates emphasized the power of exercise and nutrition; he noted, “If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health.” Over the past few decades, a bevy of research papers have supported…

Mind–Body Medicine

Overview The National Center for Complementary and Integrative Health defines Mind–Body Medicine as an approach that “focuses on the interactions among the brain, mind, body, and behavior, and on the powerful ways in which emotional, mental, social, spiritual, and behavioral factors can directly affect health.” Mind–Body Medicine may also be conceptualized as the scientifically based dimension of what was once named “Complementary and Alternative Medicine” (CAM).…

Psychopharmacologic Management of Children and Adolescents

Overview Similar to adults, hospitalized children can develop psychiatric illness as a result of psychosocial stresses of hospitalization (e.g., loss of control, threat of illness, separation from caregivers), effects of general medical conditions (e.g., infections), use of medications or substances (e.g., drug–drug interactions, drug withdrawal), and exacerbation of pre-existing psychiatric vulnerabilities. The decision to use psychotropics in this population should be based on a careful diagnostic…

Psychopharmacology in the Medical Setting

Overview The mental health professional in the general medical setting faces many challenges posed by co-morbid medical disorders and concurrent medications that hinder the detection of psychiatric symptoms and alter the effectiveness, tolerability, and safety of psychiatric drug treatment. In today's complex medical environment, many patients receive a host of medications from different specialists. As illustrated in the case study below, communication between specialties may not…

Electroconvulsive Therapy and Neurotherapeutics

Overview Treatment options in neuropsychiatry include psychotherapy, psychopharmacology, and neuromodulation. This chapter focuses on neuromodulation, a group of device-based interventions able to modulate pathologically altered brain regions and circuits using electromagnetic energy or surgical ablation. Neuromodulation therapies (also known as brain stimulation or somatic therapies) can be divided into three main groups: non-invasive, convulsive, and invasive. Non-invasive methods are applied transcranially, without the need for surgery…

Coping With Illness and Psychotherapy of the Medically Ill

Management of psychiatric illness in medically ill individuals requires knowledge of medicine and psychiatry as well as specialized psychotherapeutic techniques. In inpatient settings, challenges to compassionate psychological care are abundant (e.g., decreasing length of stays, severe medical and surgical illnesses, prominent side effects of treatment, threats to privacy, and procedures and technology that limit a patient's ability to communicate). Nonetheless, consultation psychiatrists strive to improve the…

Patients With Genetic Syndromes

Overview Genetic syndromes are disorders with a characteristic set of features that are due to an underlying common genetic mechanism, either an individual genetic mutation or a chromosomal abnormality. This chapter provides a brief overview of the genetics of major psychiatric disorders, genetic syndromes, and inborn errors of metabolism that the general psychiatrist may encounter in the hospital or clinic setting. It emphasizes several characteristics about…

Intensive Care Unit Patients

Including a chapter on the psychiatric care of patients in the intensive care unit (ICU) runs the risk of suggesting that the evaluation and treatment of patients differ depending on patients' location in the general hospital. Such a risk evokes the unfortunate misnomer “ICU psychosis,” with its erroneous suggestion that a psychotic condition can be induced by a patient's mere residence in an ICU and the…

Chronic Medical Illness and Rehabilitation

Overview Most of us take our ability to function physically (e.g., to open a tube of toothpaste, answer the telephone, tie our shoelaces, use the toilet, or comb our hair) and cognitively for granted. However, these capabilities can be lost suddenly after an accident (e.g., with a traumatic brain injury [TBI]; spinal cord injury [SCI]; an extensive burn); the onset of a debilitating chronic illness (e.g.,…

Burn Patients

Overview Burn injuries are as ancient as fire itself. All afflicted individuals need help and many require psychiatric consultation; their psychiatric care may be as challenging as their surgical care. Depending on their experience, physicians, nurses, and trainees new to a burn unit may experience trepidation and fear, but these feelings moderate as they relieve pain, help patients survive, and see the repair of disfiguring scars.…

Patients With Cancer

Overview The seriousness of the diagnosis of cancer challenges the capacity to survive, sets a course in life, and dashes hopes and dreams. Over the 20th century, even as cancer treatments improved and some patients were cured, psychiatrists in the tradition of humane psychiatry used their skills to stand by patients who were overwhelmed and helped them make complex treatment choices by which they could shape…

Patients With Human Immunodeficiency Virus Infection and Acquired Immunodeficiency Syndrome

Overview Human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS) are prevalent in disenfranchised populations, including substance users, men-who-have-sex-with-men (MSM), sex workers, ethnic minorities, and the seriously mentally ill, who all have particular difficulty advocating for and accessing adequate care. Not only is HIV infection more prevalent among the mentally ill, but psychiatric illnesses are more prevalent in those who are HIV-positive. Patients with…

Organ Failure and Transplantation

Overview Solid organ transplantation is an accepted, successful, and commonly employed treatment option for patients with end-organ failure. Transplantation recipients of a heart, liver, kidney, lung(s), pancreas, or small intestine now live longer with an overall improved quality of life. Transplantation now also offers hope to patients with severed upper limbs and to those who have suffered facial disfigurement. Progress in the development of immunosuppressive medications…

Patients With Gastrointestinal Disease

Introduction Psychiatric and gastrointestinal (GI) diseases have a bi-directional relationship that reflects a complex interplay between the central and enteric nervous systems. The assorted symptoms, sensations, and syndromes that result from this reciprocal relationship are associated with alterations in immune system functioning and modulation of neurotransmitters that are common to both systems. Psychological states of anxiety or fear may be experienced as “butterflies” in one's stomach,…

Patients With Renal Disease

Overview General hospital psychiatrists are frequently asked to consult on patients with renal disease, a patient population that accounts for approximately 4.5 million adults in the United States ( cdc.org ). Among these individuals, psychiatric consultation is most commonly requested for patients undergoing dialysis who develop depression and anxiety. However, a host of other neuropsychiatric conditions may be triggered by the psychological reactions to having renal…

The Psychiatric Management of Patients With Cardiac Disease

Overview Caring for cardiac patients can present a host of dilemmas for the general hospital psychiatrist. Patients with psychiatric conditions may exhibit cardiac symptoms, psychotropic agents can result in electrocardiographic abnormalities, and psychiatric manifestations may result from cardiac conditions. Because the overlap between psychiatry and cardiology is so great, knowledge of ways to manage specific problems can be of tremendous benefit. For instance, knowing how to…

Sexual Disorders or Sexual Dysfunction

Overview A comprehensive psychiatric evaluation of any patient in the general hospital setting should include close attention to complaints, impairments, and deviations of sexual function. Although on occasion, sexual problems are the primary reason for consultation, more often they may provide important clues about an underlying medical or psychologic condition. Consider the “difficult” patient on obstetrics who repeatedly refuses gynecologic exams, the formerly mild-mannered elderly gentleman…