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M.D._ M.P.H

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									pensive      to provide      universal     health                     Laboratory   tests                  showed that Ms.            speech,      motivation,        and social initia-
care coverage.      Ifhealth      care reform is                   L had a hemoglobin                     level of7 .3 g/dL,         tive. After three and a half weeks on
to occur in the United          States, Amen-                      a white    blood cell count                   of 10.4/cu          the inpatient          service,      she was dis-
cans   will have to let their govern-                              mm,     and normal    levels                  of electno-         charged       on halopenidol         decanoate       75
ment    representatives          at both     state                 lytes,      creatinine,          and glucose.          Chest      mg per month              and was able to live
and federal levels know that universal                             x-ray      revealed        progressive         pneumo-            independently           and attend        day treat-
health    care is important           and worth                    nia of the right lower lobe with pos-                             ment.
paying     for.                                                    sible cavitation             and increased            effu-            As Ms. L’s case illustrates,            serious
      TERRY  ZIBIN, B.S.W.,   R.S.W.                               sion. An electrocardiogram                       was sig-         self-neglect       is a common           behavioral
     DARLENE BRowN,       S.W. DIPL                                nificant        for sinus        tachycardia.           The       sequela      of schizophrenia.           Typically,
 DwIGHT     HuNKs,  B.S.W.,   R.S.W.                               admission            diagnosis         was subacute               symptoms         ofself-neglect         lead to the
                                                                   bacterial          endocarditis;           differential           patient’s      obtaining        psychiatric      care.
Theauthors         aresocialworkers            atAlberta
                                                                   diagnosis         included       infectious,       vascu-         However,         because       of factors    related
Hospital      Ponoka        in Ponoka,        Alberta.             litic,     cardiovascular,              and collagen              to economics,            access    to the health
                                                                   vascular         diseases      as well as malig-                  care system,          and the illness          itself,
Reference                                                          nancy        and nutritional              deficiencies.           many          patients        with       schizophrenia           are
                                                                   An extensive             work-up         led to a pre-            living   in poverty     and have limited
1.   Frank RG, Goldman          HH, McGuire       TG:
                                                                   sumptive           diagnosis         of scurvy,       con-        medical    care (5). Accordingly,     they
     Who will pay for health reftrm             conse-
     quences of redistribution       of funding      for           firmed        by a vitamin              C level of .1             are at risk for infectious   and metabo-
     mental healthcare.     Hospitaland     Commu-                 mg/dl (the normal                  range is .2 to 2               lic illnesses.               Although             Ms.       L made
     nity Psychiatry    45:906-910,      1994                      mg/cU).                                                           five emergency                    room        visits,    her psy-
                                                                          After vitamin          C therapy was initi-                chiatric             symptoms                  were   neither
                                                                   ated, Ms. L was able to provide                              a    identified            nor treated,             and her mcdi-
Scurvy         in Schizophrenia
                                                                   psychiatric           history      of fleeting          past      cal deterioration        continued.
To the Editor:                Scurvy,          a disorder          contact with her community                         mental             As health     service delivery     changes
caused        by severe           vitamin           C defi-        health       center.      Medication           had    been        to an emphasis           on prevention       and
ciency,      has protean           clinical       manifes-         prescribed,           but she took            it unpre-           primary     care, early identification         of
tations.       At-risk       populations            include        dictably.         Instead,      she was “blessed”                 comorbid    medical or psychiatric  dis-
single elderly men, infants,                     the urban         and absolved             of her sins. She heard                   orders will help conserve limited    re-
poor, pregnant            and lactating            women,          voices ofthe           “authorities”         informing            sources and lead to better treatment
food faddists,          and alcoholics             (1).            her of a complex              set of rules she was                of patients  with chronic    mental  ill-
     Scurvy       has also been reported                     in    required         to follow,         including        strict       ness.
psychiatric         patients        with alcoholism                dietary        restrictions.           Consequently,                                    DERRI          L. SHTASEL,              M.D.
and depression                 (2,3).        Psychiatric           she had been eating                    only rice and                    HEATHER                 KRELL,          M.D.,         M.P.H.
symptoms           described          in patients        with      beans for months.
scurvy       include       hypochondriasis,                de-             Historical           information           obtained       Dr. Sbtasel is dinical      associate professor
pression,        and hysteria               (4). Despite           from       primary           sources     was reasonably           in the department       ofpsychiatry        at the
the high incidence               ofparanoid             delu-      consistent            with     that     provided    by the        University     of Pennsylvania         School of
sions      and negative                  symptoms            in    patient:        she had been diagnosed                     as     Medicine     in Philadelphia,         where Dr.
schizophrenia,             both        of which         mdc-       having        schizophrenia, had been                   pre-      Krell    is a second-year        resident.     Dr.
pendently           contribute             to abnormal             scnibed          antipsychotic               medication           Shtasel is also a senior attending       psychia-
dietary        patterns,          little       is written          with dubious              compliance,     and was                 trist at Friends Hospital.
about       scurvy       in schizophrenia.                We       subsequently             discharged   from com-
report      such a case.                                           munity       care.       In the year preceding
     Ms. L, a 37-year-old                   African-               admission             to the medical     unit, the                References
American        woman,        was admitted          to a           patient   had made    five emergency
medical      unit of a teaching              hospital              room visits for medical    complaints;                            1. Onorato            j,     Lynfield         Y: Scurvy.       Cutis
with complaints           offever,     chills, leth-               although     medical       treatment      was nec-                      49:321-322,             1992

argy, shortness         of breath,        and knee                 ommended,        Ms. L never followed             up.             2. Jillella         1W,      Finan      ET,    Butt     ZW,    et a!:
                                                                                                                                           Case report: adultscurvy.                 Maryland      Medi-
and anide pain. Her temperature                     was                 The patient     was transferred          to the
                                                                                                                                           caijournal   39:577-578,                   1990
 102.5#{176}F. Physical        examination            re-          inpatient    psychiatry        service after two
                                                                                                                                     3.    DeSantis       J: Scurvy and          psychiatric       symp-
vealed     poor     dentition,        shorty      lym-             weeks on the medical             unit, and phar-                        toms.       Perspectives           in Psychiatric         Care
pbadenopathy,decreasedbreath                  sounds,              macologic       and psychosocial              treat-                    29:18-22,            1993
focal erythema        with warm tender               hy-           ments     were     initiated.        She showed                   4.    Kinsman          BA,Hood J: Some behavioral
perpigmented          areas on her knee and                        gradual    improvement             in positive      as                  effects ofascorbic      acid deficiency.   Amen-
ankle,    and palpable         purpura       over bi-              well as negative            symptoms         as re-                     canjourna!     ofClinica!    Nutrition   24:455-

           anterior      shins and forearms.                                                                                               464, 1971
lateral                                                            flected        by diminution                 in the        ftc-
Cardiac      and neurological             examina-                 quency    and punitive    content of audi-                        5.    Health     care reform      for           Americans      with
                                                                                                                                           severe mental illnesses:                report of the Na-
tions were unremarkable.                 A mental                  tory hallucinations,    decreased   behav-                              tional Advisory        Mental             Health  Council.
status     examination           showed         confu-             ioral “restrictions”   related to diet and                              American       Journal     of            Psychiatry       150:
sion and poverty           of speech.                              activities,          and increased           spontaneous                1447-1465,        1993



Psychiatric         Services              March        1995       Vol.46                No.3                                                                                                        293

								
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