Ethical Problems in Psychiatric Everyday Practice

Abstract: For the ethical evaluation of psychiatric decisions the will of the patient–apart from his welfare, of course–has gained special importance in recent years. It is constitutionally protected in the form of self-determination. Accordingly the physician can only act with the patient's consent. The capacity of the individual to consent may be impaired or suspended because of a mental disease. It is often difficult, however, to recognize this impairment, to assess its extent, to evaluate its current relevance and to draw the correct conclusions. This becomes important when the psychiatrist deals with a patient whose will is in opposition to his welfare. Difficulties for the physician may also result because his therapy, regardless of whether it is somatic therapy or psychotherapy or involves social measures, though aiming to remove the mental disturbance and with the ultimate objective of the patient regaining his lost autonomy in mind, may at times curtail the self-determination of the patient. These difficulties are illustrated by some examples with the objective to maintain our awareness of these issues in our everyday work.     

Urinary Side Effects of Duloxetine in the Treatment of Depression and Stress Urinary Incontinence

BACKGROUND: The efficacy and safety of duloxetine, a dual reuptake inhibitor of serotonin and norepinephrine at the recommended starting dose, have been demonstrated in the treatment of major depressive disorder (MDD) in men and women and in the treatment of stress urinary incontinence (SUI) in women. Since the mechanism of action of duloxetine in the treatment of SUI is believed to be related to enhanced urethral closure forces, it is important to clarify the risk of acute urinary retention. METHOD: The relationship between duloxetine and obstructive voiding symptoms was examined in 8 double-blind, 8- to 9-week, placebo-controlled studies and 1 open-label study in men and women treated for MDD with duloxetine 40 to 120 mg/day and in 4 double-blind, 12-week, placebo-controlled studies and 4 ongoing open-label studies in women treated for SUI with duloxetine 80 mg/day. RESULTS: In 378 men and 761 women with MDD treated in placebo-controlled trials, 0.4% (4/1139; 3 men and 1 woman) of those treated with active medication reported subjective urinary retention versus none (0/777) of those treated with placebo (p =.15). In 958 women with SUI treated with duloxetine in placebo-controlled trials, none reported subjective urinary retention. Overall, in the duloxetine placebo-controlled clinical studies in the treatment of MDD and SUI, obstructive voiding symptoms (reported either as subjective urinary retention or other obstructive voiding symptoms) occurred more often in patients receiving duloxetine (1.0%, 20/2097) than in patients receiving placebo (0.4%, 6/1732) (p <.05). Of the 4719 MDD and SUI patients treated with duloxetine in placebo-controlled and ongoing open-label studies, 2 men and 1 woman discontinued because of obstructive voiding symptoms. Although such an evaluation was not required by protocol, no cases of objective acute urinary retention with postvoid residual urine verified with a bladder scan or requiring catheterization were reported in patients treated with duloxetine. CONCLUSION: Duloxetine treatment in women and men with depression and in women with SUI was rarely associated with obstructive voiding symptoms, and no subjects had objective acute urinary retention requiring catheterization.     

Mental Health Telephone Triage: Managing Psychiatric Crisis and Emergency

PURPOSE: The study aims to identify and articulate how mental health telephone triage (MHTT) clinicians manage psychiatric crisis and emergency via the telephone. DESIGN AND METHODS: An observational design was employed in the study. Wireless headsets were used to observe 197 occasions of MHTT. FINDINGS: Clinicians use a range of practical strategies, therapeutic skills, and psychosocial interventions to manage psychiatric crises and emergencies via the telephone. PRACTICE IMPLICATIONS: The evidence base for managing psychiatric crisis/emergency in MHTT is minimal. These findings contribute to the MHTT knowledge base and provide evidence‐based strategies for high‐quality emergency mental health care.     

Psychiatric Comorbidity and Quality of Life in Patients with Post-Stroke Emotional Incontinence

Objective

We aimed to investigate the associations of post-stroke emotional incontinence (PSEI) with various psychiatric symptoms and quality of life independent of potential covariates in survivors of acute stroke.

Methods

A total of 423 stroke patients were assessed within 2 weeks of the index event. Psychiatric symptoms were assessed by the Symptom Checklist-90-Revised (SCL-90-R), which has nine domains comprising Somatization, Obsessive-Compulsive, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation, and Psychoticism. Quality of life was measured using the World Health Organization Quality of Life abbreviated form (WHOQOL-BREF), which has four domains related to physical factors, psychological factors, social relationships, and environmental context. Associations of PSEI with scores on the SCL-90-R and WHOQOL-BREF were investigated using pairwise logistic regression model adjustment for potential sociodemographic and clinical covariates.

Results

PSEI was present in 51 (12.1%) patients. PSEI was associated with the Obsessive-Compulsive, Interpersonal Sensitivity, and Hostility symptom dimensions of the SCL-90-R and with the psychological factors and social relationships domains of the WHOQOL-BREF independent of important covariates including previous stroke, stroke severity, and physical disability.

Conclusion

PSEI causes some aspects of psychiatric distress and negatively affects psychological and interpersonal quality of life. For patients with PSEI, special attention to psychiatric comorbidity and quality of life is needed, even in the acute stage of stroke.     

Evidence-Based Medicine and Psychiatric Practice

Evidence-based medicine (EBM) has been defined as the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. EBM requires the ability to apply a knowledge of medical informatics (e.g., efficiently searching the medical literature) and clinical epidemiology (e.g., being able to critically appraise the literature) to the treatment of individual patients. This article provides an introduction to the history, philosophy, and methods of EBM as applied to psychiatric practice. The article summarizes the five-step EBM model: (1) formulate the question; (2) search for answers; (3) appraise the evidence; (4) apply the results; and (5) assess the outcome. Resources (including Web sites) for further learning are provided.     

Bullying in Schools: Detection in an Adolescent Psychiatric Clinic Practice Compared with Questionnaire Survey

This pilot study compares the prevalence of bullying or being bullied as detected by postal questionnaire with that identified by the initial case-worker in a Dublin adolescent out-patient psychiatric clinic over a six months period. Of 47 consecutive clinic attenders, the 25 who responded to the questionnaire reported a substantially higher rate of bullying or victimisation than had been elicited at intake. The study also explores the severity and extent of bullying as well as the respondents' subjective experiences and reactions in an attempt to gain a mini-profile of the problem in this hitherto unresearchedpopulation.     

Management of Demented Patients with Urinary Incontinence: A Case Study

Objective: To assess whether a demented patient with urinary incontinence (UI) could learn to use an adapted version of timed voiding (i.e., instead of being led by a caregiver, the patient learns to perform timed voiding by herself). Indeed, UI affects a large number of patients with dementia and creates a substantial burden to the caregiver. UI is the most common complaint at the time of institutionalization and it is often the cause of premature institutionalization. Timed voiding is a promising intervention, but one whose effectiveness remains to be demonstrated. Additionally, timed voiding has the disadvantage of being constraining for caregivers, requiring them to be present to stimulate the patient to urinate at each of the scheduled occasions. Method: The present intervention required the patient to learn (1) to associate an auditory signal from a timer to the action of urination, (2) to reprogram the timer, using the spaced retrieval technique. An ABAB paradigm was used to assess the effectiveness of this program to eliminate urinary accidents. Results: The results of the intervention showed that the use of the timer was effective in helping the patient to reduce her urinary leaks from 1.5 diurnal accidents per week to zero during four months. Conclusion: UI in patients with dementia seems treatable. Such intervention could contribute to delay institutionalization of patients with dementia through maintaining their autonomy and reducing the burden of caregivers.     

Psychiatric Training and Practice Under Managed Care

Today's psychiatry residents are facing many challenges that were unknown to their predecessors who received training before the managed care era. The author explores such challenges including the shift in treatment approach from psychoanalysis toward neurobiology, psychopharmacology, and cognitive and behavioral models of psychopathology and psychotherapy. Other demands that practitioners in training must deal with under managed care are accountability, loss of autonomy, and administrative burdens. Despite these challenges, managed care appears to have brought about positive changes in ways that psychiatry is practiced, such as standardization of credentialing and of authorization forms, and greater use of technology to improve administrative efficiency. Most importantly, systems of care necessarily involve people working together, not in isolation, which should be the central lesson of residency training and private practice under managed care.