The dilemma of denial in the assessment of competency to refuse treatment

To illustrate the dilemma in evaluating and treating patients who deny their illness, the authors present the case of a woman with paranoia who denied she was ill and refused medication. They focus specifically on the issue of whether a patient who denies his or her illness is truly legally competent to refuse or consent to treatment. They conclude that the assessment of such competency requires a consideration of the accuracy of the patient's "appreciation of the nature of his or her situation" and that safeguards have to be built into a system for evaluating competency along these lines to prevent abuse.     

Competency to consent to medical treatment in cognitively impaired patients with Parkinson's disease

OBJECTIVES: To investigate capacity to consent to medical treatment (competency) in cognitively impaired patients with PD. BACKGROUND: Although competency has been studied empirically in patients with cortical dementia (AD), no empirical studies have examined competency in patients with PD or other subcortical neurodegenerative disorders. METHODS: Patients with PD with cognitive impairment (n = 20) and older controls (n = 20) were compared using a standardized competency measure (Capacity to Consent to Treatment Instrument [CCTI]) and neuropsychological test measures. The CCTI tests competency performance and assigns outcomes (capable, marginally capable, incapable) under four different legal standards (LS). RESULTS: Patients with PD performed below controls on the four LS: capacity to evidence a treatment choice (LS1) (p < 0.03), capacity to appreciate consequences of a treatment choice (LS3) (p < 0.03), capacity to provide rational reasons for a treatment choice (LS4) (p < 0.0001), and capacity to understand the treatment situation and choices (LS5) (p < 0.0001). With respect to competency outcomes, patients with PD demonstrated increasing compromise (marginally capable or incapable outcomes) across the four standards: LS1 (25%), LS3 (45%), LS4 (55%), and LS5 (80%). In the PD group, simple measures of executive function (the Executive Interview) and to a lesser extent memory/orientation (Dementia Rating Scale, Memory subscale) were key predictors of competency performance and outcome on the LS. CONCLUSIONS: Cognitively impaired patients with PD are likely to have impaired consent capacity, and are at risk of losing competency over the course of their neurodegenerative illness. Patients with PD have particular difficulty meeting more stringent, clinically relevant competency standards that tap reasoning skills and comprehension of treatment information. Executive dysfunction appears to be a primary neurocognitive mechanism for competency loss in PD.     

Cognitive dysfunction and competency restoration: using cognitive remediation to help restore the unrestorable

The goal of this article is to present an argument for using cognitive remediation as an adjunctive form of treatment in competency restoration programs. Clinically, it has been generally agreed that the Dusky standard requires a functional analysis of the defendant's current capacities in the current legal context; merely having a mental illness does not mean incompetency. Based on the recent literature that describes the neuropsychological deficits associated with major psychiatric illnesses such as schizophrenia, bipolar disorder, and depression, it is believed that many psychiatrically ill patients are hindered from returning to the legal process by their inability to understand and acquire the information necessary to be found competent. We argue that cognitive remediation would serve as a helpful form of treatment for incompetent patients to improve their cognitive functioning and consequently, their likelihood of being found competent.     

How to handle voluntary hospitalization afterZinermon v. Burch

By requiring states to have fair procedures for assuring the competency of patients seeking voluntary hospitalization,zinermon v. Burch will produce, legal change that may make voluntary admission more difficult. This Article analyzesZinermon and recommends administrative changes that canincrease the therapeutic potential of voluntary hospitalization. Analyzing competency from a legal and therapeutic jurisprudence perspective, the Article argues thatcompetency to assent to hospitalization should be defined narrouwly and that the competency issue should be decided by informal administrative, methods rather than adversarial judicial proceedings. The Article also examines the recent American Psychiatric Association Task Force Report recommendations on how these issues should be dealt with.     

Do psychiatric patients improve their competency to consent to hospitalization after admission? A prospective study in an acute inpatient ward

OBJECTIVES: Competency to consent to hospitalization has important clinical and ethical implications. However, there are no follow-up studies that evaluate improvement in competency during psychiatric hospitalization. The authors sought to determine whether patients admitted to a psychiatric ward as incompetent to consent to hospitalization improve their competency during hospitalization. METHOD: A total of 160 consecutively admitted patients were administered the Competency Questionnaire (CQ), a structured scale designed to assess competency to consent to psychiatric hospitalization. The CQ was administered both upon admission and at discharge. Severity and acuity of the psychiatric disorder were assessed with the Severity of Psychiatric Illness Scale and the Acuity of Psychiatric Illness Scale. RESULTS: Of the 160 assessed patients, 70 (43.8%) were rated incompetent. Forty-five of these 70 incompetent patients completed the admission-to-discharge follow-up. Twenty-one of these 45 patients (46.6%) remained incompetent at discharge. Participation in the treatment process was the only variable that predicted improvement on competency during hospitalization. Severity of psychiatric illness at admission did not predict improvement on competency. CONCLUSIONS: Nearly half of the patients who upon admission were incompetent remained incompetent at discharge.     

Consumer Focus Groups

Background: Consumer organizations involved in the Eastern Region Behavioral Health Initiative of the St. Louis Regional Health Commission sought to ensure that services were streamlined, easily accessible, and focused on consumer needs. To this end, in February 2007, they solicited feedback from consumers and family members affected by mental illness and substance abuse through a series of focus groups. Methods: Fifty-five individuals with severe mental illness and their family members, from across the St. Louis Region, shared their experiences and struggles in the mental health and substance abuse systems. The data, which were coded for six focus groups, were analyzed, summarized, and presented to system providers and community stakeholders. Results: Substantial problems still remain with medication management services, quality of inpatient care, and stigmatization. Conclusions: Consumer input is imperative to the successful implementation of any work related to systems change to both affirm and redirect organizational priorities. Stigma emerged as a pervasive theme throughout the six focus groups and was subsequently incorporated as a priority for improving services in the system. Stigma and cultural competency training is needed for health-care staff workers at all levels to increase access effectively to services.     

Teaching diagnostic approach to a patient through cinema

Films are produced with the aim of entertaining people, but recently there has been increasing use of films to educate medical trainees about various disorders, symptoms of these disorders, patient–therapist interactions, and various other medical and psychiatric issues. Discussions in academic circles have moved from criticism of negative portrayals of mental illness in earlier films to their use in teaching sessions. Films can be used either in full length or clip format to conduct training modules. Use of the film Stigmata to train residents about diagnostic dilemmas and taking a diagnostic approach to patients is discussed.     

Impairments in perceptual competency and maintenance on a visual delayed match-to-sample test in first-episode schizophrenia

BACKGROUND: Deficits in working memory (WM) have been reported in patients with schizophrenia, but WM is a complex construct dependent on several subprocesses, including input representation (perceptual competency) and holding stimuli on-line (maintenance). A visual delayed match-to-sample task (DMST) was developed to isolate perceptual competency from maintenance during delays. It was hypothesized that patients in the first episode of schizophrenia would exhibit dissociable deficits in both WM domains. METHODS: Performance on the DMST was assessed in 57 patients in the first episode of schizophrenia or schizoaffective disorder and 22 healthy comparison subjects. In phase 1 of the DMST, a complex visual stimulus (target) was followed immediately by a forced choice between 2 test stimuli, and item difficulty (differences between the test stimuli) was titrated until each subject achieved a consistent accuracy (80%-90%) in this no-delay condition. In phase 2, a delay of 4 or 8 seconds with a mask of randomly illuminated pixels was introduced between target and test stimuli; test stimuli were fixed in difficulty level based on phase 1 titration. Main outcome measures were mean item difficulty attained in the no-delay condition and mean accuracy in matching after delay. RESULTS: Compared with controls, patients attained a lower level of difficulty in the no-delay condition (P =.001) and significantly lower accuracy with delay (P =.002). CONCLUSIONS: Deficits in both domains of WM suggest abnormality in the posterior and prefrontal cortexes. These deficits can be observed in a task involving complex visual pattern stimuli using only a brief delay and are present even in unmedicated patients in the first episode of illness.     

The phenomenon of ‘chronic Lyme’; an observational study

Purposes: To chart clinical, laboratory, and psychometric profiles in patients who attribute their complaints to chronic Lyme disease. Methods: We assessed the patients by clinical examination, laboratory tests, and questionnaires measuring fatigue, depression, anxiety, health‐related quality of life, hypochondriasis, and illness perceptions. Results: We found no evidence of ongoing Borrelia burgdorferi (Bb) infection in any of the 29 included patients using current diagnostic guidelines and an extended array of tests. Eight (28%) had other well‐defined illnesses. Twenty‐one (72%) had symptoms of unknown cause, of those six met the suggested criteria for post‐Lyme disease syndrome. Fourteen (48%) had presence of anti‐Bb antibodies. The patients had more fatigue and poorer health‐related quality of life as compared to normative data, but were not more depressed, anxious, or hypochondriacal. Their beliefs about the illness were characterized by negative expectations. Conclusion: Our patients, who all attributed their symptoms to chronic Lyme disease, were heterogeneous. None had evidences of persistent Bb infection, but whether current diagnostic criteria are functional in patients with longstanding complaints is controversial. Other well‐defined illnesses or sequelae from earlier Lyme disease were probable as main explanatory factor in some cases. The patients were not more depressed, anxious, or hypochondriacal than the normal population, but they had poorer health‐related quality of life, more fatigue, and negative expectations about their illness.     

Shin-gata utsu (a new type of depression) in Japan: Social and clinical implications of the emerging phenomenon

This article is aimed at introducing and examining recent controversies raised by mental health professionals in Japan concerning what they call shin-gata utsu (a new type of depression). While clinical depression has been a serious public health concern in Japan for several decades, a new type of patient, one whose characteristics and symptoms deviate from the conventional patient profile, is appearing, primarily in workplaces. In contrast to the typical Japanese depressive patients who are workaholics, self-blaming, and middle aged or older male workers, many shin-gata utsu patients are self-centered, eager to blame others and escape from work, and more likely to be younger women. There has also been much confusion among human resource management about how to understand shin-gata utsu: Is it a form of illness eligible for workers’ compensation or simply the problem of an immature, spoilt personality? While it has never been an official diagnostic category, the increasing use of this label is suggestive of the Japanese approach to mental disorders and potentially a fundamental change in the personality of the Japanese, which could originate from their family socialization pattern. The sociocultural backgrounds for this controversy will be explored, as well as what it could mean to Japanese society.     

Assessment of psychiatric patients' competency to give informed consent: legal safeguard of civil right to autonomous decision-making

Amendment of the Mental Health and Welfare Law in Japan will limit admission for medical care and protection only for those individuals who are incapable of giving consent to admission. This is a first in the history of the Japanese mental health legislation. By reviewing the law and psychiatric literature, it is argued that: (i) informed consent is a legal transaction that embodies the idea of an individual's right to autonomous decision-making in medical settings; (ii) health professionals have a duty to protect those individuals who cannot decide medical matters because of lack of capacity to do so; (iii) some patients are marginally incompetent so assessment of their competency is essential in protecting patients' civil rights; (iv) in order for a competency assessment to be reliable (and hence fair) the method should be psychometrically sound; (v) at the same time, in order for a competency assessment to be valid, the structure of a competency assessment should match the patient's psychological, cultural, and social background; and (vi) because informed consent is a process rather than a cross-sectional event, a competency assessment should be performed in everyday practice. The use of a brief and semistructured interview to assess patients' competency to give informed consent may meet all of the requirements described.     

SCHIZOPHRENIA WITH ONSET AT THE EXTREMES OF ADULT LIFE

Objective. To define the epidemiology, phenomenology, premorbid and risk factors in patients with the first manifestation of a schizophrenia-like illness after the age of 60 years, and compare them with patients with an onset before the age of 25 years. Design/setting/subjects. All contacts for a non-affective psychotic illness across all ages of onset were ascertained through a psychiatric case register; patients were rediagnosed according to operationalized criteria for psychotic illness, and those with a very early and very late onset compared. Main outcomes measures. Phenomenological, premorbid and aetiological parameters were compared in the two groups, using risk ratios and 95% confidence intervals. Results. Very late onset patients (N=72) were, compared to their very early onset counterparts (N=192), more likely to be female, have good premorbid functioning and developmental history, and to exhibit persecutory delusions and hallucinations; they were less likely to have negative schizophrenic symptoms, to have a positive family history of schizophrenia, or have suffered pregnancy or birth complications. Conclusions. The results highlight premorbid, aetiological and phenomenological differences between patients with the onset of a schizophrenia-like illness at the extremes of adult life, and suggest it is premature to consider the two groups to be merely different manifestations of the same illness. © 1997 John Wiley & Sons, Ltd.     

Therapeutic use of classic psychedelics to treat cancer-related psychiatric distress

Abstract

Cancer is highly prevalent and one of the leading causes of global morbidity and mortality. Psychological and existential suffering is common in cancer patients, associated with poor psychiatric and medical outcomes. Promising early-phase clinical research (1960s to early 1970s) suggested a therapeutic signal for serotoninergic psychedelics (e.g. psilocybin, LSD) in treating cancer-related psychiatric distress. After several decades of quiescence, research on psychedelic-assisted therapy to treat psychiatric disorders in cancer patients has resumed within the last 2 decades in the US and Europe. This review article is based on a systematic search of clinical trials from 1960–2018 researching the therapeutic use of psychedelic treatment in patients with serious or terminal illnesses and related psychiatric illness. The search found 10 eligible clinical trials, with a total of 445 participants, with the vast majority of the patients having advanced or terminal cancer diagnoses. Six open label trials, published between 1964 and 1980 (n?=?341), suggested that psychedelic therapy (mostly with LSD) may improve cancer-related depression, anxiety, and fear of death. Four RCTs trials were published between 2011 and 2016 (n?=?104), mostly with psilocybin treatment (n?=?92), and demonstrated that psychedelic-assisted treatment can produce rapid, robust, and sustained improvements in cancer-related psychological and existential distress.     

The relationship problems of manic depressives; a preliminary study using linear analogue scales to assess relationship changes during/between illness episodes

Linear analogue scales are used in a preliminary study to assess relationship changes during/between illness episodes in manic depressives. Changes in six specific relationship characteristics are rated by a group of married manic depressives and their spouses, and these are found to differ markedly from the retrospective ratings of divorced manic depressives. The effects of episodic mental illness on relationships is discussed, and directions for future research are outlined.     

Awareness of illness and nonadherence to antipsychotic medications among persons with schizophrenia

OBJECTIVE: The purpose of this study was to assess the effects of patients' awareness of their illness on the clinical presentation, management, and course of nonadherence to antipsychotic medications among patients with schizophrenia. METHODS: A national survey was conducted of psychiatrists who were treating patients with schizophrenia. The survey was sent to 771 psychiatrists, of whom 534 responded, for a response rate of 69 percent. The psychiatrists were asked to report on presentation, management, and course for one adult patient with schizophrenia who had been under their care for at least one year and who had been nonadherent to oral antipsychotics at some point in the past year. Patients who were aware that they had a mental illness were compared with those who were not aware. RESULTS: Of the 534 respondent psychiatrists, 310 reported on an eligible patient, and 300 of these patients were classified by illness awareness. Ninety-seven patients, or 32 percent, were not aware that they had a mental illness. These patients who lacked awareness had significantly longer episodes of antipsychotic nonadherence, were more likely to completely cease taking the antipsychotic medication, were more likely to have severe positive symptoms, and were more likely to be psychiatrically hospitalized after nonadherence than those who were aware of their illness. Psychological interventions and several types of family interventions were significantly less effective among patients who lacked awareness. CONCLUSIONS: A lack of awareness of mental illness is common among patients with schizophrenia who are nonadherent to antipsychotics. Such nonadherence tends to be especially disruptive and unresponsive to simple commonly used psychological interventions.     

Are patients with bipolar affective disorder socially disadvantaged? A comparison with a control group

Background: Bipolar affective disorder (BPAD) has considerable implications for personal and social functioning. However a tendency to be over‐represented in high socio‐economic classes has been reported in earlier studies, suggesting that social disadvantage accompanying the illness is not severe. In addition, an association between affective disorders in general and increased residential mobility has been suggested, but it is unclear if such an association exists with BPAD. Objectives: (1) To investigate the suggestion made in previous studies that patients with bipolar disorder are advantaged socially. (2) To test the hypothesis that patients with bipolar disorder show greater residential mobility compared with other patients with psychiatric disorders. Method: Ninety patients with DSM IV diagnosis of bipolar disorder admitted to the acute in‐patient unit of a public‐financed district psychiatric service in Dublin were compared with a control group of 91 randomly selected patients with other psychiatric diagnoses, excluding schizophrenia. Socio‐economic, educational and employment ratings were compared, and also duration of illness, frequency of admission and residential mobility. The data were collected retrospectively from case notes and through semistructured interviews with patients or their relatives. The bipolar group was compared with the control group and to the unipolar depression subgroup. Results: The bipolar and control groups were found to have similar demographic and socio‐economic features, although the bipolar group had more years of education compared with the whole control group but not when compared with the unipolar depression group. The bipolar group showed longer duration of psychiatric disorder, more frequent hospital admissions and more frequent residential moves since the onset of the illness. Conclusion: Bipolar patients requiring in‐patient care in this service experience severe disruption to their lives over prolonged periods.     

Antecedent life events,social supports and response to antidepressants in depressed patients

We evaluated 355 subjects who entered one of six double-blind placebo-controlled antidepressant drug trials with respect to the occurrence of antecedent adverse life events and their meaning to the patient. Patients were also assessed with regard to the degree of social support they received for the negative life event. The groups differed as to whether they did or did not meet the criteria for melancholic depression; 43 one-week placebo responders were statistically significantly more likely to believe that adverse life events predisposed them to depressive illness and that such life events precipitated their current depression, compared to 312 one-week placebo non-responders. Of the 312 patients who went on to the double-blind phase in which they were treated with either drug (n= 204) or placebo (n= 108), it was noted that, for both melancholic and non-melancholic patients, responders to drug treatment (but not placebo) had a more favourable ratio of social support received/social support desired than non-responders. Non. melancholic responders to both drug and placebo were statistically significantly more likely to report fewer adverse life events and have a less strong belief that adverse life events predispose one to depressive illness than non-responders. Melancholic patients did not show this trend.     

Guillain-Barré syndrome with severe persistent disability: relationship to hyperacute Guillain-Barré syndrome

Guillain-Barré syndrome (GBS) is a heterogeneous condition with a variable prognosis. We studied nine patients who were unable to walk unaided 12 months after the onset of their illness to discover whether they belonged to a more homogeneous subgroup. Sis of the nine patients had symptoms of gastroenteritis shortly before the onset of their neuropathic symptoms and a hyperacute onset of weakness so that they were bed-bound within 24 h. These patients had predominantly motor rather than sensory involvement We compared these nine poor outcome patients with 66 patients with lesser degrees of persistent disability of whom only three had both a history of prodromal gastroenteritis and a hyperacute onset (p < 0.0001). The poor and better outcome groups did not differ significantly in the severity of disability or other clinical or neurophysiological features in the acute stage. Patients with previous gastroenteritis and hyperacute onset of weakness may represent a relatively homogeneous subgroup of “hyperacute GB” in which severe axonal damage is caused by an aberrant immune response to a gastrointestinal pathogen such as Campylobacter jejuni.     

Help-seeking Behaviors of Chinese Patients with Schizophrenia Admitted to a Psychiatric Hospital

Purpose To investigate the help-seeking behaviors and related factors of Chinese psychiatric inpatients with schizophrenia. Method Two hundred and two patients with schizophrenia (ICD-10) were enrolled in this study. A locally-developed, semi-structured questionnaire was used to collect data, including data on illness and help-seeking histories from patients, informants, and medical records. Results Among 202 inpatients, 120 patients (59.4%) had sought help from at least one type of non-psychiatric facility (NPF), and 82 patients (40.6%) went to a psychiatric hospital directly. Among the NPFs they contacted, 66 patients (32.7%) tried traditional Chinese medicine (TCM) from licensed practitioners (including acupuncturists), 64 (31.7%) chose general hospitals (including 9 who went to emergency departments), and 52 (25.7%) sought help from qigong (breathing exercise) masters or other folk healing methods. The reasons for seeking treatment from NPFs varied; the most common ones included feeling shameful or stigmatized about going to psychiatric hospitals, inaccessibility to or unavailability of psychiatric hospitals, and fear of being incarcerated or receiving electric shock treatment. Conclusion A substantial proportion of psychiatric inpatients in China seek help from non-psychiatric facilities and/or folk healing methods. Feeling shameful or stigmatized, inaccessibility to and/or unavailability of psychiatric services are among the most common barriers to seeking psychiatric treatment. Patients who sought psychiatric help directly are likely to be female, with a chronic onset of illness, a mixed syndrome of positive and negative symptoms, or a better economic status. Submitted to: Administration and Policy in Mental Health and Mental Health Services Research.