Standardized mortality ratios for psychiatric patients, derived from comparisons with the general population and matched control groups, have repeatedly demonstrated excess mortality from both natural and unnatural causes among psychiatric patients. Several large studies that have attempted to clarify the issues underlying increased death rates are discussed. Although no single diagnostic group emerges as being at particularly high risk, substance abuse disorders alone or in combination with other psychiatric disorders have been repeatedly found to lead to increased mortality rates. Other studies have also repeatedly demonstrated that psychiatric patients suffer a high rate of comorbid medical illnesses, which are largely undiagnosed and untreated and which may cause or exacerbate psychiatric symptoms. Atypical presentations are common, and changes in vision are the symptoms most predictive of medical illness. Elderly patients and those with diagnoses of organic brain syndromes are at highest risk for comorbid medical illness. Parity in the medical and mental health treatment of psychiatric patients requires both political advocacy and development of primary care programs capable of efficiently meeting their needs.

Recent studies in the rat and rhesus monkey have disclosed apparently high frequency in vivo ACTH release episodes. While the circadian pattern of plasma ACTH concentrations has been known for many years, the exact frequency of ultradian pulsatile ACTH release in man is not clear, due in part to variable intensities of blood-sampling schedules and the limited availability of sensitive ACTH assays. In this study we used a new sensitive and specific immunoradiometric assay to measure plasma ACTH concentrations in blood sampled at 1) 2-min intervals for 3 h, followed by 4-min intervals for 4 more h in six men; and 2) 10-min intervals for 24 h in eight other men. An objective peak detection algorithm (Cluster) and cosinor analyses were used to assess the episodic pulsatility and circadian rhythmicity of ACTH. Comparisons were made among the 2 min (3 h), 4, 8, and 12 min (7 h), and 10 min (24 h) time series. Mean ACTH interpulse intervals were significantly different among the five sampling groups (P less than 0.00001). Sampling every 2 min yielded a mean ACTH interpulse interval of 18 min, which was significantly shorter than the mean interpulse intervals of 35, 53, 52, and 73 min resulting, respectively, from sampling every 4, 8, 10, and 12 min (P less than 0.05). In contrast, maximal peak ACTH amplitudes (picomoles per L or percent increase) did not vary as a function of sampling frequency. The 24-h plasma ACTH concentration time series showed significant diurnal variation, with a mean circadian amplitude of 0.95 +/- 0.15 pmol/L occurring at 1008 h (+/- 25 min). Cosinor analysis of various ACTH pulse parameters deduced from the 24-h time series revealed significant circadian rhythmicity in the ACTH peak maxima (P less than 0.05), peak increments (P less than 0.05), and prepeak nadir (P less than 0.05) concentrations, but not in ACTH interpulse intervals. We conclude that in men, 1) intensive sampling at 2-min intervals unmasks high frequency ACTH release episodes that cannot be detected at conventional sampling rates; and 2) ACTH peak amplitude, but not frequency, varies significantly during the course of circadian changes in the plasma ACTH concentrations.

A majority of patients with HCV and psychiatric illness did not receive HCV treatment, and HCV infection was associated with significant mortality. Study results highlight the need to develop innovative approaches to engage such patients in HCV treatment and to successfully manage psychiatric illness during HCV treatment.

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