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Andrade NL, Shenouda R, Sockalingam S, Fipps DC. Consultation-Liaison Case Conference: Psychiatric Care of Patients Who Undergo Bariatric Surgery. J Acad Consult Liaison Psychiatry 2023; 64:267-276. [PMID: 36764484 DOI: 10.1016/j.jaclp.2023.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/20/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023]
Abstract
We present the case of a 42-year-old female with major depressive disorder who received a Roux-en-Y gastric bypass and subsequently decompensated in her depression symptoms and began newly engaging in problematic alcohol use. Top experts in the consultation-liaison field, specifically bariatric surgery psychiatry, provide guidance for this commonly encountered clinical case based on their experience and a review of the available literature. Key teaching points include the presurgical psychosocial assessment, pertinent perioperative psychopharmacology, and problematic alcohol use after bariatric surgery.
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Affiliation(s)
| | - Raymone Shenouda
- Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | | | - David C Fipps
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN.
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Ayub S, Saboor S, Usmani S, Javed S, Tonpouwo GK, Ahmed S. Lithium toxicity following Roux-en-Y gastric bypass: Mini review and illustrative case. Ment Health Clin 2022; 12:214-218. [PMID: 35801162 PMCID: PMC9190271 DOI: 10.9740/mhc.2022.06.214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 01/10/2022] [Indexed: 11/17/2022] Open
Abstract
Lithium is among the mainstays of treatment for bipolar disorder. Bariatric surgery can considerably change the oral bioavailability of drugs, particularly lithium. In this review, a 36-year-old male patient is described, who presented with lithium toxicity, including neurologic and gastric symptoms after undergoing Roux-en-Y gastric bypass. The mechanism of lithium toxicity is discussed; recommendations for clinicians regarding lithium use in postsurgical patients are provided; and previous case reports of lithium toxicity post-gastric bypass surgery are analyzed. Awareness and education of lithium absorption changes postbariatric surgery is essential for optimal patient care. Close clinical and drug concentration level monitoring is warranted.
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Affiliation(s)
- Shahana Ayub
- 1 Psychiatrist, Cornerstone Family Health, Newburgh, New York
| | - Sundas Saboor
- 2 Physician, Khyber Medical College, Peshawar, Khyber Pakhtunkhwa, Pakistan
| | | | - Sana Javed
- 4 Physician, Nishtar Medical University, Multan, Punjab, Pakistan
| | | | - Saeed Ahmed
- 6 Addiction Psychiatrist, Rutland Regional Medical Center, Rutland, Vermont
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Oprea AD, Keshock MC, O'Glasser AY, Cummings KC, Edwards AF, Zimbrean PC, Urman RD, Mauck KF. Preoperative Management of Medications for Psychiatric Diseases: Society for Perioperative Assessment and Quality Improvement Consensus Statement. Mayo Clin Proc 2022; 97:397-416. [PMID: 35120702 DOI: 10.1016/j.mayocp.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 10/15/2021] [Accepted: 11/09/2021] [Indexed: 10/19/2022]
Abstract
There is a lack of guidelines for preoperative management of psychiatric medications leading to variation in care and the potential for perioperative complications and surgical procedure cancellations on the day of surgery. The Society for Perioperative Assessment and Quality Improvement identified preoperative psychiatric medication management as an area in which consensus could improve patient care. The aim of this consensus statement is to provide recommendations to clinicians regarding preoperative psychiatric medication management. Several categories of drugs were identified including antidepressants, mood stabilizers, anxiolytics, antipsychotics, and attention deficit hyperactivity disorder medications. Literature searches and review of primary and secondary data sources were performed for each medication/medication class. We used a modified Delphi process to develop consensus recommendations for preoperative management of individual medications in each of these drug categories. While most medications should be continued perioperatively to avoid risk of relapse of the psychiatric condition, adjustments may need to be made on a case-by-case basis for certain drugs.
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Affiliation(s)
- Adriana D Oprea
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT.
| | - Maureen C Keshock
- Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Avital Y O'Glasser
- Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR
| | | | - Angela F Edwards
- Department of Anesthesiology, Wake Forest School of Medicine, Winston Salem, NC
| | - Paula C Zimbrean
- Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Karen F Mauck
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
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Coughlin JW, Steffen KJ, Sockalingam S, Mitchell JE. Psychotropic Medications in Metabolic and Bariatric Surgery: Research Updates and Clinical Considerations. Curr Psychiatry Rep 2022; 24:89-98. [PMID: 35076886 DOI: 10.1007/s11920-022-01317-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW We review evidence for assessing and monitoring psychotropic medications in metabolic and bariatric surgery (MBS) patients. We describe weight gain side effects, potential perioperative risks, pharmacokinetic changes that occur after MBS, and conclude with clinical recommendations. RECENT FINDINGS Research on psychiatric medication use and post-MBS weight outcomes is lacking and inconsistent; however, there is consistent evidence that, though variable, psychiatric medication use is associated with weight gain. Several meta-analyses and reviews provide guidance on lowering risk when appropriate. Perioperative lithium toxicity and SSRI discontinuation syndrome also warrant consideration, as do potential post-operative pharmacokinetic changes. In the absence of data for each psychiatric drug classification, close symptom monitoring and, where appropriate, serum concentration monitoring are recommended. MBS patients are a psychiatrically vulnerable population, and many are on psychiatric medications. Given potential weight/metabolic side effects, perioperative complications, and post-operative pharmacokinetic changes that occur with psychotropic medication use, providers should stay well informed on psychiatric medication management considerations.
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Affiliation(s)
- Janelle W Coughlin
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, MD, 21224, Baltimore, USA.
| | - Kristine J Steffen
- North Dakota State University, College of Health Professions, ND, 58103, Fargo, USA.,Sanford Center for Biobehavioral Research, ND, 58103, Fargo, USA
| | - Sanjeev Sockalingam
- University Health Network Bariatric Surgery Program Centre for Addiction and Mental Health University of Toronto, ON, M6J 1H4, Toronto, Canada
| | - James E Mitchell
- Sanford Center for Biobehavioral Research, ND, 58103, Fargo, USA.,University of North Dakota School of Medicine and Health Sciences, ND, 58103, Fargo, USA
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Abstract
A patient with morbid obesity and several psychiatric comorbidities underwent laparoscopic sleeve gastrectomy and experienced success with weight loss. However, she experienced lightheadedness, nausea, and a fall and was admitted to the hospital for encephalopathy due to lithium toxicity. The pharmacokinetics of lithium is altered following bariatric surgery. Due to these factors, adjustments were made to the patient’s lithium therapy, her levels were subsequently reduced into the therapeutic range, and she continued with no further issues. Mechanisms of lithium toxicity following bariatric surgery and a monitoring protocol to prevent toxicity are discussed.
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Affiliation(s)
- Suzanna Connick Jamison
- Carilion Clinic, Roanoke, VA, USA.,Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,804 Medical Brigade, Devens, MA, USA
| | - Kelley Aheron
- Carilion Clinic, Roanoke, VA, USA.,Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
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Lin YH, Liu SW, Wu HL, Kang JC, Huang KY, Huang H. Lithium toxicity with prolonged neurologic sequelae following sleeve gastrectomy: A case report and review of literature. Medicine (Baltimore) 2020; 99:e21122. [PMID: 32664138 PMCID: PMC7360221 DOI: 10.1097/md.0000000000021122] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 05/20/2020] [Accepted: 06/04/2020] [Indexed: 11/27/2022] Open
Abstract
RATIONALE Lithium is the first-line medication for bipolar disorder, given a narrow therapeutic window of 0.8 to 1.2 mEq/L. Change of lithium pharmacokinetics following bariatric surgery may lead to lithium toxicity, which is particularly concerned. PATIENT CONCERNS We presented a 39-year-old man with morbid obesity and bipolar affective disorder for 20 years, who was treated with lithium. He developed serious lithium toxicity following sleeve gastrectomy and prolonged neurologic sequelae. DIAGNOSES He suffered from persistent watery diarrhea, general weakness, and then drowsy consciousness. Lithium level was checked immediately to be 3.42 mEq/L and lithium toxicity was diagnosed. INTERVENTIONS After 3 courses of hemodialysis, his serum lithium level subsequently declined to 0.63 mEq/L, while his consciousness returned normal. Lithium was replaced by lamotrigine. OUTCOMES The patient was discharged thirty-five days after admission, while his serum lithium declined to 0.06 mEq/L. Neurologic sequelae were noted by muscle weakness and pain sensation in both feet. The nerve conduction test revealed sensorimotor polyneuropathy with conduction block. He was advised to keep a passive range of motion exercise. LESSONS Although the consensus guideline remains lacking, our report reviewed cases of relevance in the literature and highlighted the awareness of the potential risk of lithium toxicity following bariatric surgery. We suggest close monitoring of the lithium levels and perhaps a dosage adjustment for the postoperative period.
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Affiliation(s)
- Yi-Hsin Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine
| | | | - Hsein-Lin Wu
- Division of Pulmonology, Department of Internal Medicine
| | | | | | - Hsuan Huang
- Division of Pediatric Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan (R.O.C.)
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Sockalingam S, Leung SE, Wnuk S, Cassin SE, Yanofsky R, Hawa R. Psychiatric Management of Bariatric Surgery Patients: A Review of Psychopharmacological and Psychological Treatments and Their Impact on Postoperative Mental Health and Weight Outcomes. Psychosomatics 2020; 61:498-507. [PMID: 32451127 DOI: 10.1016/j.psym.2020.04.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/15/2020] [Accepted: 04/16/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Bariatric surgery is an effective treatment for severe obesity; however, high rates of psychiatric comorbidity complicate bariatric surgery care. As a result, importance has been placed on the need for ongoing psychiatric support in patients undergoing bariatric surgery. Given the lack of conclusive presurgery psychosocial predictors of postoperative mental health outcomes, studies have now shifted their focus to understand the long-term psychosocial sequalae that arise after surgery. Increasing evidence has demonstrated the potential for psychiatric care to stabilize psychiatric symptoms and minimize patient distress. OBJECTIVE To review psychopharmacological and psychological interventions for patients undergoing bariatric surgery and their impact on mental health and weight outcomes after surgery. METHODS We performed a comprehensive literature search in Ovid MEDLINE for studies examining the impact of psychopharmacological and psychological treatments on bariatric patients' postoperative mental health and weight outcomes. RESULTS Overall, 37 studies were included in the review. Preliminary evidence suggests that psychiatric medications do not negatively impact weight loss or health-related quality of life in the short term; however, more rigorous research designs are needed. There are insufficient data on specific psychiatric medications and long-term impact on weight loss and psychosocial outcomes. Postoperative psychological interventions have evidence for improving eating psychopathology, anxiety, and depressive symptoms; however, effects on weight loss remain unclear. CONCLUSION Evidence for psychopharmacological and psychological treatments remains preliminary. Consideration should be given to integrated, stepped-care models to provide personalized psychiatric interventions after surgery. Future research on expanding current psychiatric interventions, timing of delivery, and predictors of response is needed.
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Affiliation(s)
- Sanjeev Sockalingam
- Centre for Mental Health, University Health Network, Toronto, ON, Canada; Bariatric Surgery Program, Toronto Western Hospital, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Department of Education, Centre for Addiction and Mental Health, Toronto, ON, Canada.
| | - Samantha E Leung
- Centre for Mental Health, University Health Network, Toronto, ON, Canada; Bariatric Surgery Program, Toronto Western Hospital, Toronto, ON, Canada
| | - Susan Wnuk
- Centre for Mental Health, University Health Network, Toronto, ON, Canada; Bariatric Surgery Program, Toronto Western Hospital, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Stephanie E Cassin
- Centre for Mental Health, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Department of Psychology, Ryerson University, Toronto, ON, Canada
| | - Richard Yanofsky
- Centre for Mental Health, University Health Network, Toronto, ON, Canada; Bariatric Surgery Program, Toronto Western Hospital, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Raed Hawa
- Centre for Mental Health, University Health Network, Toronto, ON, Canada; Bariatric Surgery Program, Toronto Western Hospital, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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Abstract
Severe obesity has many psychiatric consequences that can be influenced by bariatric surgery. The goal of this article is to review these challenges, including the mental health status of patients with severe obesity, the evaluation of surgical candidates, and the early and late effects of the operations, and to offer some recommendations to manage these challenges. The failure of the insurance-mandated preoperative psychosocial evaluation is also discussed.
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Affiliation(s)
- Michael D Morledge
- Department of Psychiatry and Behavioral Medicine, Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Walter J Pories
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
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Bishop-Freeman SC, Skirnick O, Noble CN, Eagerton DH, Winecker RE. Effects of Bariatric Surgery Observed in Postmortem Toxicology Casework. J Anal Toxicol 2019; 43:651-659. [PMID: 31424074 DOI: 10.1093/jat/bkz062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/03/2019] [Accepted: 05/07/2019] [Indexed: 12/28/2022] Open
Abstract
Bariatric surgery has been on the rise and patients often have multiple indications for pre- and post-operative pharmacotherapy. Procedures target the stomach and/or small intestine and affect weight loss through restriction, malabsorption, or a combination of the two. The absorption and/or metabolism of drugs via the gastrointestinal tract could be altered by different mechanisms. Several cases at the North Carolina Office of the Chief Medical Examiner's Toxicology Laboratory (NCOCME) have raised questions about the potential impact of these procedures on the disposition of drugs in the body and how that altered disposition may affect cause and manner of death. Overmedication and postmortem redistribution are not enough to explain the phenomena seen in some NCOCME bariatric surgery-related casework. Case examples include a 46-year-old female with a history of Roux-en-Y gastric bypass (RYGB) who suffered a witnessed collapse. Toxicological findings included elevated concentrations of oxymorphone at 0.49 mg/L in vena cava blood. A 67-year-old female, who died from vomiting and bacterial gastritis one day after placement of two intragastric weight-loss balloons, had elevated concentrations of duloxetine at 1.4 mg/L in the iliac vein blood and 9.3 mg/kg in the liver. Her medication was strictly controlled by her sister and gastric contents were without intact tablets or residue at autopsy.
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Affiliation(s)
| | - Olivia Skirnick
- North Carolina Office of the Chief Medical Examiner, Raleigh, NC, USA
| | | | - David H Eagerton
- Campbell University, College of Pharmacy and Health Sciences, Buies Creek, NC, USA
| | - Ruth E Winecker
- Center for Forensic Sciences, RTI International, Research Triangle Park, NC, USA
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Dahan A, Porat D, Azran C, Mualem Y, Sakran N, Abu-abeid S. Lithium Toxicity with Severe Bradycardia Post Sleeve Gastrectomy: a Case Report and Review of the Literature. Obes Surg 2019; 29:735-8. [DOI: 10.1007/s11695-018-3597-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wasserman B, Jiang W. Lithium Toxicity after Roux-en-Y Gastric Bypass is Not Just Limited to Perioperative Period. Psychosomatics 2017; 59:206. [PMID: 29174690 DOI: 10.1016/j.psym.2017.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 10/10/2017] [Indexed: 11/15/2022]
Affiliation(s)
| | - Wei Jiang
- Psychiatry and Behavioral Sciences, Duke University, Medicine, Durham, NC.
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Duarte-Guerra LS, Coêlho BM, Santo MA, Lotufo-Neto F, Wang YP. Morbidity persistence and comorbidity of mood, anxiety, and eating disorders among preoperative bariatric patients. Psychiatry Res 2017; 257:1-6. [PMID: 28709116 DOI: 10.1016/j.psychres.2017.07.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 07/01/2017] [Accepted: 07/10/2017] [Indexed: 11/26/2022]
Abstract
The current study investigates the patterns of disease persistence and comorbidity of psychiatric disorders among patients with class III obesity in pre-operative period. For 393 treatment-seeking patients with severe obesity recruited from a bariatric center, we ascertained their psychiatric diagnosis through Structured Clinical Interview for DSM-IV (SCID-I). Following, the frequency, persistence and comorbidity pattern of psychiatric disorders in this sample were determined. Current psychiatric disorders were observed in over half of patients during preoperative period, being anxiety disorders the most frequent diagnosis. For lifetime disorders, mood disorders were the most frequent diagnosis. Most of the sample presented 2 or more concurrent lifetime psychiatric disorders. While mood and eating disorders were frequent conditions, anxiety disorders were the most persistent conditions (the highest one month-to-lifetime prevalence ratio) and were significantly correlated with bipolar, depressive and eating disorders. Psychiatric disorders are frequent and enduring conditions among patients looking for bariatric surgery. Comorbid anxiety, mood, and eating disorders are remarkable features in treatment-seeking patients with obesity. Prognostic implications of preoperative psychiatric disorders on surgery outcome should be demonstrated prospectively in intervention studies.
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Affiliation(s)
| | - Bruno Mendonça Coêlho
- Department and Institute of Psychiatry (LIM-23), University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Marco Aurélio Santo
- Department of Surgery, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Francisco Lotufo-Neto
- Department and Institute of Psychiatry (LIM-23), University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Yuan-Pang Wang
- Department and Institute of Psychiatry (LIM-23), University of São Paulo Medical School, São Paulo, SP, Brazil.
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Taylor JB, Stern TA. Meeting Its Mission: Does Psychosomatics Align With the Mission of Its Parent Organization, the Academy of Psychosomatic Medicine? Psychosomatics 2017; 58:375-385. [PMID: 28449827 DOI: 10.1016/j.psym.2017.03.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/05/2017] [Accepted: 03/06/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND The vision and mission statements of the Academy of Psychosomatic Medicine (APM) indicate that the APM should promote excellence in clinical care for patients with comorbid psychiatric and general medical conditions by seeking to influence research, public policy, and interdisciplinary education. OBJECTIVE As the APM owns the journal, Psychosomatics, we sought to assess whether the APM's journal was fulfilling the vision and mission of its parent organization by reviewing the content of articles published in the journal to determine whether it sufficiently addresses the various clinical care knowledge areas it seeks to influence. METHODS We categorized content in all review articles, case reports, and original research articles published in Psychosomatics in 2015 and 2016. Each article was assigned to as many categories that it covered. RESULTS In the 163 articles reviewed, the most frequently covered fund of knowledge area was psychiatric morbidity in medical populations (44.2%); among psychiatric disorders, mood disorders (22.1%), psychiatric disorders due to a general medical condition or toxic substance (21.5%), anxiety disorders (14.7%), and delirium (13.5) were the most frequently covered. Of the medical and surgical topics, neurology (19.6%), coping with chronic illness/psychological response to illness (17.8%), toxicology (11.7%), outpatient medicine (10.4%), and cardiology (9.8%) appeared most often. CONCLUSIONS Psychosomatics appears to be successfully providing content relevant to the APM's vision and mission statements and to practitioners of psychosomatic medicine.
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Affiliation(s)
- John B Taylor
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA.
| | - Theodore A Stern
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
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