Psychological and social evaluation in cases of deliberate self-poisoning admitted to a general hospital.

In a prospective clinical trial 312 cases of self-poisoning (276 patients) consecutively admitted to hospital were randomly allocated to medical teams or to psychiatrists for an initial psychiatric assessment and a decision as to "disposal." Junior doctors and nurses received some instruction in this work. Both groups of assessors asked for help from social workers when necessary. Once the medical teams had completed their assessments, psychiatrists provided most of the hospital treatment. Follow-up at one year showed no significant difference between the two groups of patients in the numbers who repeated their self-poisoning or self-injury (or both), or committed suicide. Provided junior doctors and nurses are taught to assess self-poisoned patients, we think medical teams can evaluate the suicidal risk and identify patients requiring psychiatric treatment or help from social workers, or both. Contrary to the Department of Health''s recommendation that all cases of deliberate self-poisoning should be seen by psychiatrists, we have reached the conclusion that physicians should decide for each of their patients if specialist psychiatric advice is necessary.     

WPA guidance on how to combat stigmatization of psychiatry and psychiatrists

In 2009 the WPA President established a Task Force that was to examine available evidence about the stigmatization of psychiatry and psychiatrists and to make recommendations about action that national psychiatric societies and psychiatrists as professionals could do to reduce or prevent the stigmatization of their discipline as well as to prevent its nefarious consequences. This paper presents a summary of the Task Force’s findings and recommendations. The Task Force reviewed the literature concerning the image of psychiatry and psychiatrists in the media and the opinions about psychiatry and psychiatrists of the general public, of students of medicine, of health professionals other than psychiatrists and of persons with mental illness and their families. It also reviewed the evidence about the interventions that have been undertaken to combat stigma and consequent discrimination and made a series of recommendations to the national psychiatric societies and to individual psychiatrists. The Task Force laid emphasis on the formulation of best practices of psychiatry and their application in health services and on the revision of curricula for the training of health personnel. It also recommended that national psychiatric societies establish links with other professional associations, with organizations of patients and their relatives and with the media in order to approach the problems of stigma on a broad front. The Task Force also underlined the role that psychiatrists can play in the prevention of stigmatization of psychiatry, stressing the need to develop a respectful relationship with patients, to strictly observe ethical rules in the practice of psychiatry and to maintain professional competence.     

Consultation-liaison scheme for self-poisoned patients in a general hospital.

In a prospective clinical trial 276 self-poisoned patients consecutively admitted to hospital were randomly allocated to medical teams or to psychiatrists for an initial psychiatric assessment and a decision about "disposal." Junior doctors and nurses received instruction in this work. While awaiting the outcome of the trial the randomisation was continued for 13 months and 729 allocations were made altogether. Physicians requested psychiatric opinions for roughly one in five of their patients. In other respects medical teams performed similarly to psychiatrists. Provided that due attention is given to teaching junior staff and to ensuring that psychiatric treatment and social-work support are available once patients have been assessed, such a consultation-liaison scheme could be adopted in other hospitals. This would help to change unfavourable attitudes towards self-poisoned patients and contribute to the general training of doctors and nurses.     

Diagnostic differences in psychogeriatric patients in Toronto,New York and London,England.

National statistics on psychiatric illness in the elderly patient from Canada, the United States and the United Kingdom suggest great differences in morbidity in these three centres. The present study shows that these differences stem mainly from different diagnostic habits in the three countries, but also there were more alcoholics in the Canadian sample. In particular, the diagnostic bias of the New York psychiatrists towards diagnosing most elderly patients as senile was not shared by their Toronto colleagues. Some patients were psychiatrically well, in spite of receiving a psychiatric diagnosis, and could have been helped without hospitalization. In addition, some depressed patients were labelled senile. Recommendations include improvement of catchment and treatment facilities for the elderly alcoholic and the provision of psychogeriatric diagnostic centres.     

Psychiatric Nurse as Therapist

Under supervision five nurse-therapists have treated phobic patients as successfully as have psychiatrists and psychologists using similar psychological treatments in comparable psychiatric populations. Nurses have also had good results in other neurotic disorders. Intensive training is required. Nurse-therapists find their work rewarding, but the present Salmon gradings make no provision for their advancement should they retain their clinical function. Results suggest that the use of selected psychiatric nurses as skilled therapists can ease the current critical shortage of treatment personnel in psychiatry.     

Drug abuse,psychiatric disorders,and AIDS. Dual and triple diagnosis.

Substance abuse and psychiatric disorders commonly occur together. This form of dual diagnosis is notable because it complicates assessment and makes treatment more difficult for both psychiatric and drug abuse problems. Drugs can cause psychiatric disorders and can also be used as an attempt to "cure" them by self-medication. The spread of the human immunodeficiency virus (HIV) among drug users has added a third potential clinical problem, that of the acquired immunodeficiency syndrome, to the difficulties already presented by drug abuse and psychiatric disorders. Patients with this triple diagnosis pose challenges to primary care physicians as well as addiction medicine specialists or psychiatrists. Assessment should include a drug abuse history, preferably corroborated by others, evaluation of the mental state, and examination focusing on signs of drug abuse and HIV infection. Treatment should include the management of HIV disease, abstinence from drug abuse, and access to psychiatric care. New systems of health care service, including interdisciplinary case management, may be needed to manage patients with a triple diagnosis.     

Psychiatrists' attitudes regarding genetic testing and patient safeguards: a preliminary study

AIMS: A probability sample of U.S. psychiatrists (n = 93) was invited to complete a mail survey regarding the likely impact of genetic testing on psychiatry; the clinical utility of pharmacogenetic, diagnostic, and susceptibility genetic testing; and 14 proposed ethical and legal safeguards for clinical genetic testing. RESULTS: Forty-five psychiatrists participated in the survey (response rate = 48%). The majority (80% and 60%, respectively) believed that genetic testing would benefit many psychiatric patients and would dramatically change the way psychiatry is practiced. Many psychiatrists (73-85%) also stated that pharmacogenetic, diagnostic, and susceptibility tests for common psychiatric disorders would be somewhat useful or extremely useful in the clinical setting. Nearly all (98-100%) believed that psychiatrists should obtain informed consent before genetic testing, should keep test results confidential, should provide pre- and posttest counseling, and should demonstrate competence in interpreting test results. Nearly all (96-100%) supported laws and regulations to prevent discrimination based on genetic test results and to protect consumers from misleading advertisements for testing. Ninety-one percent endorsed restrictions on the sale of genetic tests directly to consumers. CONCLUSIONS: This probability sample of U.S. psychiatrists expressed a strongly positive view of genetic testing in psychiatry, while voicing nearly unanimous support for seven ethical and legal safeguards.     

Psychiatry in General Practice

Psychiatrists should include the family doctor in their plans for future psychiatric services. The general practitioner now treats most of the patients who seek help for psychiatric disorder and he could not give up his psychiatric practice even if he wanted to. Furthermore, there are not now nor will there ever be enough psychiatrists to take over all patients with mental ills. Most emotionally disturbed patients can be better handled by their family physicians than by a specialist.To provide the best care for emotionally disturbed people the communication between family doctors and psychiatrists must be improved. The specialist must acknowledge the importance of the general practitioner''s role in psychiatric diagnosis and treatment and give him more help. Medical schools must provide better undergraduate and postgraduate psychiatric training for the students who will become family doctors. Health plans and other prepayment agencies should properly compensate the general practitioner for giving psychiatric treatment. The specialist in psychiatry should consult more readily with the general practitioner and help him carry out some of the therapy. General hospitals should permit family doctors to admit mental patients to psychiatric wards in a general hospital and to carry out psychiatric treatment with the help of the specialist in psychiatry.     

Psychiatry in the Soviet Union

The services for chronically handicapped people with psychiatric disorders in the Soviet Union are described. The system is based upon a network of community units, each of which includes a day centre, a follow-up clinic, and a sheltered workshop. British services could profitably learn from the experience of these units. The diagnostic system used by many Soviet psychiatrists is different from that incorporated in the International Classification of Diseases. In particular, the term “schizophrenia” is used to describe conditions which British psychiatrists would label in other ways.This clinical difference partly explains the different concept of “criminal responsibility,” but another large component of the difference is political rather than medical. There are also variations from British practice in certain juridical procedures. These differences together make Soviet psychiatric practice in the case of political dissenters unacceptable to most British psychiatrists. It is too soon to say that frank discussions of these matters could not lead to improvement. British and Soviet psychiatrists still have something to learn from each other.     

Psychiatric morbidity of a long stay hospital population with chronic schizophrenia and implications for future community care.

In the United Kingdom there are plans to close most mental hospitals over the next 10 years. There is continuing uncertainty about the effectiveness of community psychiatric services that will be expected to cope with mental hospital inpatients after discharge, most of whom have schizophrenia. A survey was conducted to assess the severity of illness among such patients and implications for their future care. All 222 patients in non-psychogeriatric long stay wards of a mental hospital who met research diagnostic criteria for schizophrenia were interviewed by two psychiatrists with the comprehensive psychopathological rating scale to establish the prevalence of psychiatric symptomatology. A complete interview was not possible for 28 patients, mainly for reasons related to their schizophrenia. Despite energetic pharmacological and social treatments almost half of the 194 patients interviewed had enduring florid psychotic symptoms that presented as one or more delusions or auditory hallucinations, or both, and a sizable proportion showed behaviour that would set them apart in a community setting. The results illustrate a problem that is still imperfectly understood by policy makers and administrators in central and local government and in health authorities who are responsible for planning and implementing services for psychiatric care in the community.     

Establishing irremediable psychiatric suffering in the context of medical assistance in dying in the Netherlands: a qualitative study

Background:Establishing irremediability of suffering is a central challenge in determining the appropriateness of medical assistance in dying (MAiD) for patients with a psychiatric disorder. We sought to evaluate how experienced psychiatrists define irremediable psychiatric suffering in the context of MAiD and what challenges they face while establishing irremediable psychiatric suffering.Methods:We conducted a qualitative study of psychiatrists in the Netherlands with experience assessing irremediable psychiatric suffering in the context of MAiD. We collected data from in-depth, semistructured interviews focused on the definition of irremediable psychiatric suffering and on the challenges in establishing irremediability. We analyzed themes using a modified grounded theory approach.Results:The study included 11 psychiatrists. Although irremediable psychiatric suffering is a prospective concept, most participants relied on retrospective dimensions to define it, such as a history of failed treatments, and expressed that uncertainty was inevitable in this process. When establishing irremediable psychiatric suffering, participants identified challenges related to diagnosis and treatment. The main diagnostic challenge identified was the frequent co-occurrence of more than 1 psychiatric diagnosis. Important challenges related to treatment included assessing the quality of past treatments, establishing when limits of treatment had been reached and managing “treatment fatigue.”Interpretation:Challenges regarding the definition, diagnosis and treatment of irremediable psychiatric suffering complicate the process of establishing it in the context of MAiD. Development of consensus clinical criteria for irremediable psychiatric suffering in this context and further research to understand “treatment fatigue” among patients with psychiatric disorders may help address these challenges. Registration: This study was preregistered under osf.io/2jrnd.

Medical assistance in dying (MAiD), also known as physician-assisted death, has been legalized in an increasing number of jurisdictions around the world.¹ In 2023, Canada will join a small group of countries that allow MAiD for people with mental illness, more commonly referred to as persons with a psychiatric disorder. ² In the Netherlands, MAiD for irremediable psychiatric suffering has been approved by jurisprudence since the 1990s and it has been regulated by law since 2002. The last decade has seen a marked increase in MAiD for irremediable psychiatric suffering; in 2020, MAiD was performed 88 times for psychiatric suffering (1.3% of all MAiD cases), compared with just 2 instances in 2010.³ The number of requests by patients with a psychiatric disorder is much higher, but 90% of requests do not end in MAiD. Sometimes, they are retracted by patients, but most are denied by psychiatrists.⁴The main legal requirements for MAiD in the Netherlands are that the patient must be able to make a competent request, that the patient’s suffering must be unbearable and irremediable, and that the patient and physician agree that there are no other reasonable treatment options. The process for MAiD requires an assessment by an independent physician and, in the case of psychiatric suffering, a third assessment by an independent psychiatrist, preferably one with specific expertise regarding the patient’s disorder.⁵ The Canadian legal requirements under the amended Bill C-7, which will come into effect in 2023, will be largely similar to the Dutch requirements.⁶ However, Canadian legislation, which does not yet permit MAiD for mental illness, has 1 important difference: patients with decision-making capacity can qualify for MAiD if they refuse treatments that they do not find acceptable. It is as yet unknown whether this approach to refusal of treatment will also be applied to MAiD where mental illness is the sole underlying condition.Although there are concerns about decision-making capacity, the central dilemma of MAiD for patients with a psychiatric disorder appears to revolve around applying the concept of irremediability to psychiatric disorders. The 2018 guideline by the Dutch Psychiatry Association defines irremediable psychiatric suffering in the context of MAiD as follows: “irremediability means that there is no longer any prospect of alleviating, mitigating, enduring or removing suffering. There is no longer a reasonable treatment perspective.”⁷ Elsewhere, the guideline states that reasonable treatment perspective means that “there is a prospect of improvement with adequate treatment, within a foreseeable period, and with a reasonable ratio between the expected results and the burden of the treatment for the patient.”⁷A recent scoping review identified a multitude of conceptual articles addressing irremediability in the context of psychiatric MAiD but few empirical studies.¹ This suggests that the assessment of irremediable psychiatric suffering is particularly difficult relative to suffering arising from other types of conditions.Surveys estimate that 46% of psychiatrists in the Netherlands have received an explicit MAiD request at least once in their career, and 4% actually assisted in the death of a patient with a psychiatric disorder.⁸ The experiences of psychiatrists who have handled MAiD requests can be seen as an important source of knowledge about the challenges of establishing irremediable psychiatric suffering in practice. The aim of this study was to learn how experienced psychiatrists define psychiatric suffering as irremediable in the context of a MAiD request and what challenges they face while establishing irremediable psychiatric suffering.     

Efficacy of a Regional Poisoning Treatment Centre in Preventing Further Suicidal Behaviour

A survey of parasuicide (attempted suicide) in general practice in Edinburgh allowed comparison of the rates of further suicidal behaviour in patients treated for their initial episode in the Edinburgh Regional Poisoning Treatment Centre and in those referred to psychiatrists elsewhere or not referred at all. Further suicidal behaviour was only one-third as common among those treated in the treatment centre as among non-admitted patients; patients referred to other psychiatric services did no better than those who were not referred to a psychiatrist at all. The difference in repetition frequencies could not be accounted for in terms of selection of patients in the treatment centre who were less likely to repeat. The tentative conclusion is made that crisis intervention of the kind available at the Edinburgh centre is effective in secondary prevention. The findings add support to Government recommendations that special units like the one in Edinburgh should be set up in other regions.     

Attitudes of Ontario psychiatrists towards health insurance.

In 1979 the opinions of Ontario psychiatrists were sought regarding the influence of the Ontario Health Insurance Plan (OHIP) on the practice of their specialty. Full replies to a 44-item questionnaire were received from more than half the certified psychiatrists in Ontario, half of whom had been in practice before the introduction of OHIP. Both satisfaction and uneasiness were expressed about most aspects of health insurance. Many of the 416 psychiatrists stated that OHIP had improved access to psychiatric care, providing a more socially diverse practice, especially with respect to psychotherapy. Only one quarter believed that OHIP constituted a major intrusion on the doctor-patient relationship, and the majority reported that OHIP had been beneficial to themselves as psychiatrists (70%) and to their patients (86%). Almost half reported having raised their concern about the confidentiality of OHIP records with their patients; the patients less often brought up the issue. Although most psychiatrists in practice before the introduction of OHIP reported no change in their conduct of psychotherapy, a minority reported a decrease in the duration of treatment and an increase in the frequency of missed appointments. Also noted was an increase in the number of referrals for consultation, which led at times to overutilization of these specialists'' services.     

Prescribing psychotherapy

Psychotherapy has long been an integral treatment modality for patients with psychiatric conditions, but recent evidence suggests that the practice of psychotherapy by psychiatrists has greatly diminished. Between 1996 and 2005, the percentage of psychiatry office visits involving psychotherapy decreased from about 44% to 29%, a 35% reduction in less than 10 years. Although the increasing availability of medications to treat psychiatric disorders has played a role in this decline, it is not the only factor. This essay reviews the multiple forces effecting this shift and highlights the limited knowledge base regarding the impact of this change on patients. The essay concludes with a call for research to prevent unintended and potentially harmful consequences to patients and to inform the continued role of psychotherapy in residency education.     

Increased CSF levels of somatostatin in patients with brain tumours and intracranial hypertension

The cerebrospinal fluid (CSF) levels of somatostatin in patients with brain tumours, communicating hydrocephalus, lumbar-disc disease (treated as a control) were measured by specific radioimmunoassay. The somatostatin concentration in the patients with brain tumours and intracranial hypertension was significantly higher compared to those with brain tumours and normal CSF pressure. CSF somatostatin content in patients with communicating hydrocephalus, was similar to patients with brain tumours and normal CSF pressure, and did not show a significant difference from the control group. The authors discuss possible reasons for such results obtained in patients with brain tumours and intracranial hypertension.     

Psychiatric services in general hospitals: a report of the Northern California Psychiatric Society's committee on the need for psychiatric services in general hospitals

A study made by a special committee appointed for the purpose by the Northern California Psychiatric Society found that a real need exists for local psychiatric services in general hospitals of the Northern California area. Such services can be provided readily-and in some communities are already available. A broad segment of the population looks to the general hospital to provide diagnosis and care and so enable the patient's prompt recovery from psychiatric disorders. The study further emphasizes the importance of such factors as a competent psychiatric chief, adequate staff and personnel and good planning in organizing inpatient and outpatient facilities and integrating treatment so that all the functions of the hospital are available to psychiatric patients. Granted these special considerations, the services can be provided more easily than many physicians, including some psychiatrists and administrators, suppose.     

Family Life and Social Medicine: Discourses and Discontents Surrounding Puebla’s Psychiatric Care

Drawing on clinical data from 15 months of on-site participant observation in the only public psychiatric hospital in the state of Puebla, Mexico, this article advances our understanding of globalization in relation to psychiatry. I challenge the construction of psychiatry as only treating the individual patient and provide grounded doctor-patient-family member interaction in a Mexican psychiatric clinic in order to review what happens when doctors cannot interact with patients as atomized individuals even though in theory they are trained to think of patients that way. Challenged by severe structural constraints and bolstered by lessons from other nations’ efforts at deinstitutionalization, psychiatrists in Puebla push to keep patients out of the inpatient wards and in their respective communities. To this end, psychiatrists call upon co-present kin who are identified both as the customer and part of the caretaking system outside the clinic. This modification to the visit structure changes the dynamic and content of clinical visits while doctors seamlessly respond to unspoken beliefs and values that are central to local life, ultimately showing that efforts to define a “global psychiatry” informed by global policy will fail because it cannot exist in a uniform way—interpersonal interaction and personal experience matters.     

PSYCHIATRIC SERVICES IN GENERAL HOSPITALS—A Report of the Northern California Psychiatric Society's Committee on the Need for Psychiatric Services in General Hospitals

A study made by a special committee appointed for the purpose by the Northern California Psychiatric Society found that a real need exists for local psychiatric services in general hospitals of the Northern California area. Such services can be provided readily—and in some communities are already available. A broad segment of the population looks to the general hospital to provide diagnosis and care and so enable the patient''s prompt recovery from psychiatric disorders. The study further emphasizes the importance of such factors as a competent psychiatric chief, adequate staff and personnel and good planning in organizing inpatient and outpatient facilities and integrating treatment so that all the functions of the hospital are available to psychiatric patients. Granted these special considerations, the services can be provided more easily than many physicians, including some psychiatrists and administrators, suppose.     

Violence and psychosis. II--Effect of psychiatric diagnosis on conviction and sentencing of offenders.

An examination of the records of all sick and violent men remanded to a large English prison suggested a tendency among police to consider men to be exceptionally dangerous simply because of their mental illness. On further study, however, there was no evidence that the mentally ill were more vulnerable to detention without subsequent conviction than their normal peers. Remand was rarely followed by help for the mentally abnormal men studied; this is disturbing as requests for psychiatric help constitute an important reason for custodial remand. Less than a third of the men with active symptoms went to hospital, although some of the less disturbed received supervision (including probation) orders, occasionally with treatment. As there is evidence that most of the few mentally abnormal offenders who subsequently receive treatment benefit from it, psychiatrists should do more for offender patients.