Can the patient-physician relationship survive in the era of managed care?

The author discusses the history of the patient-physician relationship and considers how recent developments in the health care system have affected the viability of that relationship. He first considers the justification for maintaining such a relationship and concludes that the patient-physician relationship must be preserved because it has a long history, is humane and ethical, and is cost effective. The author then reviews the ethical basis that forms the foundation of the patient-physician relationship. He discusses issues related to competency, commitment, compassion, equanimity, and patient advocacy. The article concludes with a consideration of the medical-ethical dilemmas created in the patient-physician relationship by managed care.     

Is managed care ethical?

The author identifies ethical dilemmas inherent in fee-for-service medicine (grounded in patients' autonomous decision making) and managed care (grounded in the principle of efficiency). He argues that the moral legitimacy of the latter system of health care is more in question, and suggests a methodology for assessing its ethical status.     

In the wake of the Matisse RCT: What about art therapy and psychosis?

Abstract

The Matisse RCT carried out by Crawford and colleagues in 2012 suggested that for many people with a diagnosis of schizophrenia, art therapy as conducted in that trial may have no benefit. This article aims to contribute to identifying what might be learnt from Matisse, help art therapists defend their work and, where appropriate, help people retain access to it. Mental health work is still strongly influenced by the difficult history of schizophrenia. Aspects of Matisse and what it managed to test are questioned. The article argues that the British Medical Journal editorial review of the trial, though generally well considered, is mistaken to consider that Matisse tested art therapy as currently practised in the UK. It is important to design future research trials that test art therapy approaches specifically adapted for use with people who experience psychosis. Ideas about recovery (which are in the social psychiatry lineage of art therapy), and the growing strength of service user movements worldwide, indicate that there are ways forward for work and research in this area. Art therapy is not a stand-alone approach for people with these diagnoses, but it can contribute to combinations of treatments and there is still some evidence that it can aid service engagement and counter negative symptoms.     

Is three a crowd? Clients, clinicians, and managed care

How does therapy change when therapists work under managed care plans? To explore this question, the authors conducted in-depth, semistructured interviews with therapists. The interview texts were analyzed using a structured thematic coding system. A central theme in the interviews was a culture clash between managed care companies and these therapists. Working for managed care organizations demanded several practices that violated the therapists' standard of care and professional ethics. Also, participants reported that managed care personnel misrepresented the nature of psychotherapy to clients, thereby undermining the therapeutic work and the therapist-client relationship. If these therapists' experiences are representative, the growth of managed care has serious implications for the nature of psychotherapy, practitioners' integrity and morale, and the public image of the therapy professions.     

What's inside the art? The influence of frontotemporal dementia in art production

We evaluated the productions of an artist with frontotemporal lobar degeneration from before dementia onset until she was fully symptomatic. We noted an improvement of technique that might be related to sparing and disinhibition of the right posterior neocortex. There was a reduction of closure (completeness of the painting), possibly induced by impersistence and a decrease in evocative impact that might be explained by frontal and anterotemporal-limbic dysfunction.     

Family burden and relatives' participation in psychiatric care: are the patient's diagnosis and the relation to the patient of importance?

BACKGROUND: Studies that differentiate among diagnoses have detected divergent results in the experience of family burden. AIM: This study aimed to investigate differences in family burden and participation in care between relatives from subgroups of psychoses, affective disorders and 'other diagnoses', and between different subgroups of relatives. METHOD: In a Swedish longitudinal study performed in 1986, 1991 and 1997, 455 close relatives of both committed and voluntarily admitted patients were interviewed concerning different aspects of their burden, need for support and participation in the actual care situation. RESULTS: Relatives showed burdens in several of the aspects measured. In only one aspect of the investigated burden items was a difference found between different diagnostic subgroups. The relatives of patients with affective disorder more often had to give up leisure time. However, spouses showed more burdens and more often experienced sufficient participation in the patient's treatment than other subgroups while siblings more seldom experienced burdens and more seldom felt that their own needs for support had been met by the psychiatric services. Within each diagnostic subgroup there were differences between subgroups of relatives. CONCLUSION: Being a close relative, and living together with a severely mentally ill person in an acute situation, is one factor of importance for experiencing burden and participation in care, contradicting the conventional wisdom which differentiates between diagnoses.     

Antipsychotics for the prevention and treatment of delirium in the intensive care unit: what is their role?

Delirium affects up to 80% of critically ill patients, worsens outcomes, and is frequently treated with antipsychotics despite uncertainty regarding their efficacy and safety. We identified published, English-language, randomized, controlled studies evaluating antipsychotics in ICU patients either with delirium or at risk for developing delirium. In 105 mechanically ventilated patients, the number of days spent alive without delirium or coma was similar between haloperidol (median, 14.0 days; interquartile range [IQR], 6.0-18.0 days) or ziprasidone (median, 15.0 days; IQR, 9.1-18.0 days) prophylaxis, and placebo (median, 12.5 days; IQR, 1.2-17.2 days) groups (p=0.66). Treating delirium with quetiapine, compared to placebo, in 36 ICU patients was associated with a quicker resolution of delirium (median for quetiapine, 1.0 days; IQR, 0.5-3.0 days/median for placebo, 4.5 days; IQR, 2.0-7.0 days [p=0.001]). In a third study, a similar decrease over time in delirium severity was noted between fixed-dose oral olanzapine and oral haloperidol in patients with delirium. None of the studies identified serious safety concerns with administering the antipsychotics that were studied. Published prospective, randomized clinical trials evaluating antipsychotic therapy for preventing or treating delirium in the ICU are few in number. The conclusions that can be drawn from them are limited by their heterogeneity, inconsistency in incorporating non-antipsychotic strategies known to reduce delirium or in maintaining patients in an arousable state, their size, the lack of ICU and non-ICU clinical outcomes evaluated, and the lack of placebo arms. A research framework for future evaluation of the use of antipsychotic therapy in the critically ill is proposed.     

Staff and patient perspectives on the purpose of psychotropic prescribing in prisons: care or control?

Objective

The objective was to explore perspectives on reasons for psychotropic medication use in prisons.

Method

We recruited a purposive sample of healthcare staff and patients prescribed psychotropic medicines from four East of England prisons. Participants took part in qualitative, semistructured interviews, which were recorded, transcribed and analyzed thematically.

Results

While patients and healthcare staff viewed psychotropic medicines primarily as a treatment for reducing symptoms of mental illness, they were also used as a coping strategy and to reduce insomnia. Appropriate psychotropic prescribing was also thought to contribute towards the rehabilitation agenda and helped to maintain order in prisons. Staff voiced concerns regarding possible overreliance on psychotropic medicines. However, patients perceived insufficient access to alternative, nonpharmacological forms of treatment and support in prison.

Conclusion

Psychotropic medicines are used for multiple purposes in prisons and are generally considered a useful resource. Nonetheless, further work may be needed to find the right balance between psychotropic medicines and alternative, nonpharmacological therapies.