Nursing problems in intensive care for psychiatric patients]

Two cases illustrate psychotherapeutic aspects of surgical intensive cares for psychiatric patients. Comparison with their style of expression in art-therapy allows a better understanding in their relations with the technical and non human environment.     

Alcohol problems in psychiatric patients: 5-year course

Little is known about the occurrence and course of alcohol problems in patients with affective syndromes treated in psychiatric facilities. We have shown previously that a high proportion of such patients abused alcohol. In a 5-year follow-up of patients in the initial study, a large majority had a remission of their alcohol problems lasting at least 6 months, although many of these patients had subsequent relapses. Using survival analyses, we found that alcohol dependence indicators, previous chronicity of alcohol problems, and a diagnosis of schizoaffective disorder predicted poor outcome (specifically, longer time to remission of the alcohol problems). However, these factors were unrelated to receiving alcohol-specific treatment during the 5 years. Severity of social/occupational alcohol problems did not predict poor outcome, but did predict alcohol-specific treatment (detoxification, rehabilitation, Alcoholics Anonymous [AA], or Antabuse).     

Legal and ethical issues relevant to HIV-positive psychiatric patients

Three major legal and ethical issues central to the AIDS epidemic--capacity to consent to testing, degree of dangerousness, and duty to warn third parties--are examined, as they influence the management of psychiatric patients.     

Suicide among psychiatric patients in Fukuoka Prefecture]

To investigate suicide among psychiatric patients in Japan (mainly Fukuoka prefecture), a questionnaire survey was submitted to psychiatrists from departments of psychiatry of university hospitals in Japan, departments of psychiatry of Rosai Hospitals in Japan, psychiatric hospitals in Fukuoka prefecture, psychiatric clinics in Fukuoka prefecture, and departments of psychiatry of general hospitals in Fukuoka prefecture regarding their psychiatric patients who died from suicide (266 females and 267 males). A large proportion of the patients at completed suicide was aged within the thirties to fifties. The majority of patients suffered from either F3 (mood disorders) or F2 (schizophrenia, schizotypal and delusional disorders) categories of the ICD-10 classification. Approximately one-fifth of the patients in Fukuoka prefecture had jobs at the time of completed suicide. The main "occupational risk factors" that were found to be risks for suicide were "failure or overloaded responsibilities in their jobs" and "worsening business situation". The main "other risk factors", i.e., risk factors other than "occupational risk factors" were "worsening psychiatric conditions", "personal life events (e.g., somatic illness or marital discord)" and "life events in other family members (e.g., familial discord or familial problems)". Over 50% of all cases had both "occupational risk factors" and "other risk factors", suggestive of the necessity for multidimensional evaluation and care in the treatment of suicidal patients. Given that numerous males that suffer from psychiatric disorders commit suicide without seeing a psychiatrist, it is important to establish a system to treat them appropriately in order to prevent unnecessary deaths.     

Legal issues in psychiatric treatment

This paper has presented a discussion of the three overlapping phases in the regulation of psychiatric treatment: consent, patients' rights, and physicians' duties. The concepts of consent are relatively well defined. Still, the courts sometimes utilize the rubric of consent to decide difficult cases (e.g., Clites). One can predict that litigation attempting to further define the specific aspects of consent for high-risk therapies will continue. Because of the court's decision in Youngberg, one can also predict that there will be more litigation as to the constituents of constitutionally-adequate treatment. Given the court's dicta in that case, about deferring to professional judgment, it is impossible to know how these cases will fare if and when they are reviewed by the Supreme Court. Given the court's decisions in Mills and Rennie, it is unlikely that the Supreme Court will be ruling on a broad constitutionally-based right to refuse treatment for some time. The most active interface of psychiatry and law is that detailing physicians' duties. In terms of dangerousness, the majority of cases require that psychiatrists attempt to protect victims, or classes of victims, when they believe that dangerous conduct is apt to occur. Still unclear is the extent to which the courts will inquire specifically into the clinical decision-making process to determine whether the physician "reasonably should have known" that the patient was dangerous. Also unclear is the extent to which the courts will find that physicians owe a duty to an ill-defined class. Still, a reasonable guess would be that other courts will find Lipari persuasive. Finally, with regard to specific treatment modalities, it is evident that physicians are being required to practice with an extra measure of care and caution when prescribing neuroleptics, ECT, or psychosurgery. One final note: Too often, physicians have been leery of the political process. Since many decisions with great impact on patients and practitioners are political, this author would urge physicians to engage in that process to secure more reasonable and more equitable medical regulation.     

Conversion symptoms of patients in psychiatric liaison care]

At the consultation-psychiatric service of a large university hospital conversion disorders present ca. 50% of the "somatoform disorders". The rate of incidence of conversion disorders was 4% of all patients seen in the service, i.e. 20-30 referrals per annum. A report on 103 patients referred during 1987-1990 is given concerning basic sociodemographic data, symptom clusters, course of illness, age at onset of the disorder, psychiatric and family history, psychosocial conditions and intrapsychic conflicts, additional affective disorders and psychophysiological symptoms, illness behaviour, cognitive attitudes towards illness. The rate of 35% patients showing an underlying somatic disorder in addition to their conversion symptoms had to be appreciated. Possible relations of conversion disorders to affective illness, somatization disorder and neurologic disease had to be discussed as to course of illness and theoretical concepts.     

Legal pitfalls of psychiatric research

BACKGROUND: The increasing complexity of psychiatric research, including recent attempts to evaluate mental health legislation, suggests legal advice may be valuable in a wide range of research contexts. AIMS: We aim to illustrate both the legal pitfalls of research in psychiatry and the potential for solutions if the methods are carefully chosen. METHOD: Two examples of research are subject to legal analysis, one involving advance directives, the other the random discharge of compulsory out-patients. RESULTS: This analysis illustrates that participation in research may expose clinicians to additional forms of liability, but the legal risks can be minimised through changes in the methods or additional safeguards. CONCLUSIONS: Collaboration between academic law and psychiatry can enrich research agendas and avoid serious legal pitfalls. We argue that sound legal advice should be sought at the planning stage of research in psychiatry, but the fear of liability should not lead to overly defensive research practices. The aim should be to strike the right balance between avoiding unacceptable exposure to liability and stifling innovative research.