Letters
derlying depression. When we were referred a case of a patient who had end-stage Parkinson's disease, whose symptoms were no longer responding to medical management, we first verified that the patient was not experiencing depression and then started him on a regimen of ECT.
Case Report Mr. K. is a 71-year-old white male with a diagnosis of both severe Parkinson' s disease and status post major depression. single episode in full remission. His medications were as follows: I. 2. 3. 4. 5.
Carbidopa-levodopa (Sinemet) Lorazepam (Ativan) Dephenhydramine hydrochloride (Benadryll Desipramine hydrochloride (Norpramin) Propantheline bromide (pro-Banthine)
The patient was found to be doing poorly on consultation; he shuftled into the office with great difficulty and with the assistance of his wife and a nurse. There was obvious freezing on a momentto-moment basis. He had a marked parkinsonian appearance, although he was still fairly upright. Cogwheeling and rigidity were present. We assessed the patient and found that he did experience some mild dementia; there was no evidence of a depressive illness. We did a Beck Depression Inventory. and the patient scored in the area which showed no depressive symptoms. Six unilateral ECTs were done under general anesthesia. The patient achieved good relaxation and seizure activity. No complications were noted.
At the end of the above course of treatment, we again assessed the patient. This assessment consisted of interviews with the patient's clinical staff, getting his opinions as well as the opinions of family members who saw him on a regular basis. The findings of all of these people are summarized. We found that the patient showed an improvement after each ECT treatment. However, these improvements were transient, and the patient quickly returned to his previous level of functioning. This correlates with the "on-off'
phenomenon noted by Anderson et al.~ However, our improvements were much shorter in duration than those noted by Anderson. This is an important negative finding in that, in a patient with no signs of depression, there was little or no improvement in the patient's long term parkinsonian outlook; yet we believe that, because of our careful screening for depressive symptoms, it represents an important piece of data. We continue to believe that ECT for Parkinson's disease should be further studied. We also feel that all further studies of ECT in Parkinson's disease should be carefully controlled for depressive illness. Matthew Berger. M.D. Wyoming Valley Psychiatric Association. P.c. Scranton. Pennsylvania Danilo A. de Soto. M.D. New Castle. Delaware
References I. Lieberman AN: The use of adrenal medullary and fetal grafts as a trealJl1ent for Parkinson's disease. NY Srale.l Med XX:2X7-2X9. 19XX 2. Fink M: ECT for Parkinson's disease? (editorial). CO/lI'lIlsin' Thera"r -t: I X9-191. 19XX 3. Baruch P. Jouvent R. Vindreau R. et al: Improvement of parkinsonism in ECT-treated depressed patients: Parkinson's disease or depression-related extrapyramidal disorder" in Biological Psrcllialrr. 19X5: Proceedi/lgs o(lhe WIll World CO/lgress o(Biological Psychialry. Edited by Shagass C. New York. Elsevier. 19X6 -to Douyon R. Serby M. Klutchko B. et al: ECT and Parkinson's disease: a naturalistic study. Alii .I Psychialry 1-t6:11.19X9
5. Anderson K. Balldin J. GOltfries CG. el al: A double-blind evaluation of electroconvulsive therapy in Parkinson's disease with "on-off' phenomena. Aera Nellrol SnJlld 76:191-199.19X7
On Improving Psychiatric Consultation to Nonpsychiatrist Physicians SIR: The article by Thompson et aI., "Improving Psychiatric Consultation to Nonpsychiatrist Physicians,'" is an important addition to our knowledge of quality assurance in consultation-liaison psychiatry. The nonpsychiatrist physicians surveyed (70 respondents out of 200 questionnaires PSYCHOSOMATICS
Letters
sent) revealed that a major reason they do not consult a psychiatrist is a lack of communication of findings and recommendations by psychiatric consultants. Psychiatrists must be held at least partially accountable for this lack of communication unless psychiatrist-patient confidentiality is the obstacle to sharing knowledge with the consultee. On the other hand, nonpsychiatrist physicians may be held accountable for poorly communicated consultations. One study found that a majority of psychiatric consultation requests lacked description of specific symptoms to be evaluated or questions to be answered. 2 Another study demonstrated an inverse relationship between clarity of consultation request and severity of psychiatric illness diagnosed by the psychiatric consultant. 1 An experienced psychiatric consultant often finds hidden agendas behind psychiatric consultations, which the consultee may not want to read on the chart. or even to address face to face. These difficulties in communication contribute to the way in which psychiatrists are at times seen as communicating less than optimally with our consultees. Zigun~ developed a "Psychiatric Consultation Checklist." with which he has demonstrated superior clarity of psychiatric consultation requests over nonstructured consultation requests. It would be interesting to assess the compliance of non psychiatrist consultees with such a form over an extended period of time. Though time-consuming. I believe there is no substitute for the physician-to-physician phone call. both before and after the consultation. In this way. certain delicate interpersonal and political matters. as well as straightforward psychiatric findings, can be explained (perhaps taught) to the nonpsychiatrist consultee. It would be helpful to have empirical evidence that those of us in consultation-liaison psychiatry are better able to communicate our findings to our consultees and. as a result. produce greater "customer satisfaction." Such empirical evidence might go a long way toward proving that consultationliaison psychiatrists perform a unique and valuable service which deserves funding for postgraduate training and. perhaps. subspecialty status. VOLUME .11· NUMBER 4· FALL ('I'll)
David K. Gittelman. M.D. Department of Psychiatry University of North Carolina Chapel Hill. North Carolina
References I. Thompson TL. Wise TN. Kelley AB. et al: Improving psychiatric consultation to nonpsychiatrist physicians. pSYc!IO.wmal;n 31 :HO-X4. 1990 2. Ries RK. Bokan JA. Kleinman A. et al: Psychialric consultation-liaison: patients. requests. and functions. Ct'll Hosp P.Hcll;alrl' 3:204-212. 19HO 3. Gollinger R. Teitelbaum ML: Clarity of request for consultation: its relationship to psychiatric diagnosis. P.I'ycllO.wmm;n 26:649-653. 19X5 4. Zigun JR: The psychiatric consultation checklist: a structured form to improve the clarity of psychiatric consultation requests. Cell Hosp Psycll;all'v 12:36-44. 1990
In Reply SIR: Dr. Gittelman's letter in response to the paper that we co-authored. "Improving Psychiatric Consultation to Nonpsychiatrist Physicians:' raises several issues. We suggest that psychiatrists be sparing in our criticism of nonpsychiatrist physicians for poorly communicated consultation requests since these often retlect why they need the consultation. Instead. we might be glad they are consulting us when they become aware that they cannot clearly articulate what is going on psychiatrically instead of "burying their heads in the sand," In fact. those who cannot describe the specific symptoms to be evaluated or who cannot formulate the questions to be answered usually are in greatest need of our help with their patients and our subsequent education of them on psychiatric matters. In at least one sense, the Gollinger and Teitelbaum study results. referred to by Dr. Gittelman. make perfect sense. That is. those who cannot request a psychiatric consultation in clear terms might not be expected to recognize psychiatric conditions as clearly or as promptly as someone who can logically and cogently describe most of the situation psychiatrically. Therefore, patients of the relatively confused consultee might have to become tloridly psychotic or develop other psychiatric pathology to a more severe degree before the 467
derlying depression. When we were referred a case of a patient who had end-stage Parkinson's disease, whose symptoms were no longer responding to medical management, we first verified that the patient was not experiencing depression and then started him on a regimen of ECT.
Case Report Mr. K. is a 71-year-old white male with a diagnosis of both severe Parkinson' s disease and status post major depression. single episode in full remission. His medications were as follows: I. 2. 3. 4. 5.
Carbidopa-levodopa (Sinemet) Lorazepam (Ativan) Dephenhydramine hydrochloride (Benadryll Desipramine hydrochloride (Norpramin) Propantheline bromide (pro-Banthine)
The patient was found to be doing poorly on consultation; he shuftled into the office with great difficulty and with the assistance of his wife and a nurse. There was obvious freezing on a momentto-moment basis. He had a marked parkinsonian appearance, although he was still fairly upright. Cogwheeling and rigidity were present. We assessed the patient and found that he did experience some mild dementia; there was no evidence of a depressive illness. We did a Beck Depression Inventory. and the patient scored in the area which showed no depressive symptoms. Six unilateral ECTs were done under general anesthesia. The patient achieved good relaxation and seizure activity. No complications were noted.
At the end of the above course of treatment, we again assessed the patient. This assessment consisted of interviews with the patient's clinical staff, getting his opinions as well as the opinions of family members who saw him on a regular basis. The findings of all of these people are summarized. We found that the patient showed an improvement after each ECT treatment. However, these improvements were transient, and the patient quickly returned to his previous level of functioning. This correlates with the "on-off'
phenomenon noted by Anderson et al.~ However, our improvements were much shorter in duration than those noted by Anderson. This is an important negative finding in that, in a patient with no signs of depression, there was little or no improvement in the patient's long term parkinsonian outlook; yet we believe that, because of our careful screening for depressive symptoms, it represents an important piece of data. We continue to believe that ECT for Parkinson's disease should be further studied. We also feel that all further studies of ECT in Parkinson's disease should be carefully controlled for depressive illness. Matthew Berger. M.D. Wyoming Valley Psychiatric Association. P.c. Scranton. Pennsylvania Danilo A. de Soto. M.D. New Castle. Delaware
References I. Lieberman AN: The use of adrenal medullary and fetal grafts as a trealJl1ent for Parkinson's disease. NY Srale.l Med XX:2X7-2X9. 19XX 2. Fink M: ECT for Parkinson's disease? (editorial). CO/lI'lIlsin' Thera"r -t: I X9-191. 19XX 3. Baruch P. Jouvent R. Vindreau R. et al: Improvement of parkinsonism in ECT-treated depressed patients: Parkinson's disease or depression-related extrapyramidal disorder" in Biological Psrcllialrr. 19X5: Proceedi/lgs o(lhe WIll World CO/lgress o(Biological Psychialry. Edited by Shagass C. New York. Elsevier. 19X6 -to Douyon R. Serby M. Klutchko B. et al: ECT and Parkinson's disease: a naturalistic study. Alii .I Psychialry 1-t6:11.19X9
5. Anderson K. Balldin J. GOltfries CG. el al: A double-blind evaluation of electroconvulsive therapy in Parkinson's disease with "on-off' phenomena. Aera Nellrol SnJlld 76:191-199.19X7
On Improving Psychiatric Consultation to Nonpsychiatrist Physicians SIR: The article by Thompson et aI., "Improving Psychiatric Consultation to Nonpsychiatrist Physicians,'" is an important addition to our knowledge of quality assurance in consultation-liaison psychiatry. The nonpsychiatrist physicians surveyed (70 respondents out of 200 questionnaires PSYCHOSOMATICS
Letters
sent) revealed that a major reason they do not consult a psychiatrist is a lack of communication of findings and recommendations by psychiatric consultants. Psychiatrists must be held at least partially accountable for this lack of communication unless psychiatrist-patient confidentiality is the obstacle to sharing knowledge with the consultee. On the other hand, nonpsychiatrist physicians may be held accountable for poorly communicated consultations. One study found that a majority of psychiatric consultation requests lacked description of specific symptoms to be evaluated or questions to be answered. 2 Another study demonstrated an inverse relationship between clarity of consultation request and severity of psychiatric illness diagnosed by the psychiatric consultant. 1 An experienced psychiatric consultant often finds hidden agendas behind psychiatric consultations, which the consultee may not want to read on the chart. or even to address face to face. These difficulties in communication contribute to the way in which psychiatrists are at times seen as communicating less than optimally with our consultees. Zigun~ developed a "Psychiatric Consultation Checklist." with which he has demonstrated superior clarity of psychiatric consultation requests over nonstructured consultation requests. It would be interesting to assess the compliance of non psychiatrist consultees with such a form over an extended period of time. Though time-consuming. I believe there is no substitute for the physician-to-physician phone call. both before and after the consultation. In this way. certain delicate interpersonal and political matters. as well as straightforward psychiatric findings, can be explained (perhaps taught) to the nonpsychiatrist consultee. It would be helpful to have empirical evidence that those of us in consultation-liaison psychiatry are better able to communicate our findings to our consultees and. as a result. produce greater "customer satisfaction." Such empirical evidence might go a long way toward proving that consultationliaison psychiatrists perform a unique and valuable service which deserves funding for postgraduate training and. perhaps. subspecialty status. VOLUME .11· NUMBER 4· FALL ('I'll)
David K. Gittelman. M.D. Department of Psychiatry University of North Carolina Chapel Hill. North Carolina
References I. Thompson TL. Wise TN. Kelley AB. et al: Improving psychiatric consultation to nonpsychiatrist physicians. pSYc!IO.wmal;n 31 :HO-X4. 1990 2. Ries RK. Bokan JA. Kleinman A. et al: Psychialric consultation-liaison: patients. requests. and functions. Ct'll Hosp P.Hcll;alrl' 3:204-212. 19HO 3. Gollinger R. Teitelbaum ML: Clarity of request for consultation: its relationship to psychiatric diagnosis. P.I'ycllO.wmm;n 26:649-653. 19X5 4. Zigun JR: The psychiatric consultation checklist: a structured form to improve the clarity of psychiatric consultation requests. Cell Hosp Psycll;all'v 12:36-44. 1990
In Reply SIR: Dr. Gittelman's letter in response to the paper that we co-authored. "Improving Psychiatric Consultation to Nonpsychiatrist Physicians:' raises several issues. We suggest that psychiatrists be sparing in our criticism of nonpsychiatrist physicians for poorly communicated consultation requests since these often retlect why they need the consultation. Instead. we might be glad they are consulting us when they become aware that they cannot clearly articulate what is going on psychiatrically instead of "burying their heads in the sand," In fact. those who cannot describe the specific symptoms to be evaluated or who cannot formulate the questions to be answered usually are in greatest need of our help with their patients and our subsequent education of them on psychiatric matters. In at least one sense, the Gollinger and Teitelbaum study results. referred to by Dr. Gittelman. make perfect sense. That is. those who cannot request a psychiatric consultation in clear terms might not be expected to recognize psychiatric conditions as clearly or as promptly as someone who can logically and cogently describe most of the situation psychiatrically. Therefore, patients of the relatively confused consultee might have to become tloridly psychotic or develop other psychiatric pathology to a more severe degree before the 467
