Psychosomatics 46:498-499, October 2005
doi: 10.1176/appi.psy.46.5.498
© 2005 Academy of Psychosomatic Medicine
Manual of Psychiatric Care for the Medically Ill
Edited by Antoinette Ambrosino Wyszynski, M.D., and Bernard Wyszynski, M.D., Arlington, Va., American Psychiatric Publishing, Inc., 2005, 416 pages, $64.00, ISBN 1-58562-118-8
Mary Alice O’Dowd, M.D.
This book is the successor to A Case Approach to Medical Practice by the husband-and-wife team of Antoinette Ambrosino Wyszynski, M.D., a consultation-liaison psychiatrist, and Bernard Wyszynski, M.D., a psychiatrist and neurologist. Their goal was to produce a basic, practical manual for the psychiatric diagnosis and management of the medically ill during the "small slice of care" that may be allowed by the pressures on physician time and length of stay. They aim at "succinctness and practicality," focusing on the consultation process. By intent, not every topic is covered, and the Drs. Wyszynski chose to give separate chapters to only a few disorders: delirium, HIV, hepatitis C, and steroid-induced psychiatric syndromes, as well as a primer on solid organ transplants. Much of the rest of the manual is devoted to strategies for managing psychiatric manifestations in patients with cardiovascular, hepatic, renal, pulmonary, or gastrointestinal disorders. The book concludes with extensive appendixes.
The initial chapter on the delirious patient provides a practical overview of diagnosis and treatment. Several vignettes present typical clinical scenarios and are followed by questions for discussion. After a review of the causes of delirium, the authors discuss the bedside assessment, including practical suggestions for the interview, a review of screening instruments (with their strengths and weaknesses), and a checklist of supportive interventions for the delirious patient with the mnemonic "SPOCCC." This is the first of many lengthy mnemonics embraced by the Drs. Wyszynski. For someone still trying to remember my own mnemonic for hypnopompic versus hypnogogic phenomena from my residency days, if I could remember all of these mnemonics, I would be smart enough not to need them.
The brief discussion of suicidal behaviors in Tables 5 and 6 seems to miss the point, combining risk assessment in patients with psychological stressors or clear suicidal ideation with the risk in delirium, which is often related to confusion, hallucinations, and agitation, but the discussion of medication regimens in the management of delirium is practical. The next few chapters focus on disorders of particular organ systems and their psychiatric manifestations. Chapter 2 deals with hepatic disease and alcohol dependence, with a clear table differentiating between the withdrawal syndromes, the deliria, and the dementias seen in this population. Here and elsewhere, the Drs. Wyszynski have pulled together instruments that have clinical use, with several figures and tables presenting withdrawal assessments and questionnaires for identifying the problem drinker. The chapter concludes with outlines for the management of withdrawal. I would have liked a discussion of the management of prolonged withdrawal in the medically ill patient here.
The next chapter deals with cardiovascular disease. After a brief discussion of the interaction between stress, anxiety, depression, and cardiac illness, as well as some of the psychological ramifications of having a pacemaker or implantable cardioverter-defibrillator, the major focus of the chapter is on psychotropic medications, their side effects, and possible drug-drug interactions. Although the discussion focuses for the most part on more "modern" medications, there is also a table on the cardiovascular side effects of the tricyclic antidepressants and monoxamine oxidase inhibitors (MAOIs). The table on cardiac-psychotropic drug interactions, more of an everyday issue than the use of MAOIs, is brief, but there are references as to where more detailed information can be found. The use of antipsychotics, including issues related to QTc prolongation, and mood stabilizers round out the chapter.
Chapter 4 covers the treatment of the patient with kidney disease, briefly discussing neuropsychiatric abnormalities in kidney failure and as a response to dialysis before moving on to psychopharmacology in renal failure. The use of lithium in renal failure and drug interactions that may lead to lithium toxicity or subtherapeutic lithium levels are reviewed. The chapter concludes with psychological factors that may be seen in the patient with end-stage renal disease. A similar outline is followed in the next two chapters on pulmonary and gastrointestinal disorders. The obstetric patient is the focus of chapter 7, moving from treatment of psychiatric disorders before conception to issues in pregnancy and throughout the postpartum period. The authors are eager to include as much information as possible in a brief space, which can be confusing because boxes, figures, and tables follow one another in rapid succession. Despite the emphasis on being concise, the same material is sometimes repeated from section to section or even on the same page. Appendixes to this chapter discuss psychotropic drugs in pregnancy and lactation.
The next four chapters deal with more specific situations—patients using steroids, AIDS/HIV patients, patients with hepatitis C—and a primer on solid organ transplant psychiatry. The HIV chapter is the longest and most detailed, The reliance on the clinician’s use of the mnemonic "VINDICTIVE MADS," explained in Appendix 4, for the differential diagnosis of mental status change might be helpful for the beginning clinician. The last five chapters quickly cover assessing decisional capacity and informed consent, an overview of coping styles and psychological issues in medical patients, dealing with the spiritual and the seriously ill patient, and finally, the physician as comforter.
There are 253 pages of text with appendixes that are almost half as long, at 110 pages. Space limitations prevent the listing of all 19 appendixes, some only a page in length and others seeming more deserving of the title of "chapter." Some of the lengthier mnemonics are explained; there are checklists and guidelines, worksheets for organizing the consultation, decision trees, delirium rating scales, a guide to herbal supplements, risk factors for torsades de pointes, and more. I was puzzled by the inclusion of guidelines for screening for bipolar disorder and for monitoring patients receiving atypical antipsychotics as these topics seem to belong in a more general psychiatry text. The final appendix is a series of case vignettes and study guides. The questions posed are an excellent review, and page numbers are provided to reference the material in the questions.
The guidelines, study guides, and questions suggest that this book would be most useful to residents doing a psychosomatic medicine rotation or a fellowship. However, there is material in every chapter that could be used by the more seasoned clinician. The Drs. Wyszynski have succeeded in their goal of providing a manual that addresses many of the most common consultation issues. As such, it can stand on its own but is also a fine complement to a more complete textbook. Is it just my imagination that even the colors of the cover harmonize so beautifully with the Levenson text? I look forward to rereading this with my residents and have already had occasion to use it as a reference. I would also urge the Wyszynskis to consider adding a volume II to cover some of the areas omitted here.
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FOOTNOTES
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Dr. O’Dowd is Director of Psychosomatic Medicine at Montefiore Medical Center and Professor of Clinical Psychiatry at Albert Einstein College of Medicine, Bronx, N.Y.
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