News

In a surprising 7-2 ruling in May, the U.S. Supreme Court held that a condemned inmate was entitled to federal habeas corpus review of his death sentence based on claims of mental incompetence. Writing for the majority, Chief Justice William O. Rehnquist let stand a 9th U.S. Circuit Court of Appeals ruling that delayed the execution of an Arizona prisoner pending a sanity determination in federal court.

While there is broad-ranging support for increased resources for the mentally ill, the degree to which innovations should include mandated care has re-ignited a long-standing debate over whose civil rights are actually being trampled-those individuals who are forced to receive care, or those who are denied care even though they desperately need it.

Nonprofit health maintenance organizations (HMOs) state that their goal is to serve the public, whereas the main goal of for-profit HMOs is profit generation. One might assume, therefore, that the operating procedures of these two types of HMOs would be different from one another. A recent experience of mine, however, suggests otherwise.

Women and their special needs regarding addiction was the topic of a recent two-day conference held at New York University (NYU).

Inside Out

This is the fourth in a series of five articles regarding obsessive-compulsive spectrum disorders. The first three articles ran in the March 1997, June 1997 and January 1998 issues of Psychiatric Times. The first article gave an overview of spectrum disorders, the second discussed obsessive-compulsive disorder and the third examined body dysmorphic disorder.

For reasons researchers are still trying to understand, clinical depression appears to be almost twice as common in women as in men. Why females are more prone to this debilitating disease than their male counterparts is still under investigation, although significant progress has been made.

A New Drug Application was submitted to the U.S. Food and Drug Administration in May for the selective norepinephrine reuptake inhibitor (SNRI) antidepressant, reboxetine. The manufacturer, Pharmacia & Upjohn, has marketed the antidepressant as Edronax in the United Kingdom since July 1997, and in October 1997 received approval through the European Mutual Recognition Procedure to distribute it in 11 other European Union Countries during 1998.

Among the specialized refugee population in the United States, there is little research on the gender differences in psychological distress, which is considerable. Southeast Asian refugee women have been identified as an at-risk group for developing serious psychiatric disorders primarily due to their premigration experiences.

Differences between the sexes regarding the prevalence, psychopathology and natural history of psychiatric disorders have become the focus of an increasingly large number of epidemiological, biological and psychological studies. A fundamental understanding of sex differences may lead to a better understanding of the underlying mechanisms of diseases, as well as their expression and risks.

The department of psychiatry at Columbia-Presbyterian Medical Center (CPMC) in New York City has opened one of the first facilities in the country that brings the techniques of complementary medicine to psychiatry. The Center for Meditation and Healing, which opened this March, emphasizes traditional meditative methods used for thousands of years in Asian cultures, particularly those of India and Tibet.

Just as the first scattered incidents of homicide involving urban children in the early 1980s were not isolated episodes precipitated by "criminally ill" children, the recent episodes of school homicide in nonurban middle-class America, including the massacre in Littleton, Colo., are not isolated incidents of violence involving seriously "mentally ill" children.

The Office for Protection from Research Risks (OPRR), an agency operating under the aegis of the U.S. Department of Health and Human Services, launched an investigation in April aimed at determining whether young boys were endangered during the course of experiments involving the drug fenfluramine (Pondimin).

A leader of a key mental illness patient advocacy group indirectly but pointedly criticized psychiatrists for the care they give schizophrenics. Laurie Flynn, the executive director of the National Alliance for the Mentally Ill (NAMI), said she was "appalled" by the results of face-to-face interviews with over 700 schizophrenics during a 16-month period. The interviews turned up evidence of under- and overdosing of patients and a failure to get patients into effective community treatment plans.

It is now obvious to most knowledgeable observers that managed care will transform the American health care system. Managed care brought competitive market forces into medicine, and demonstrated that the right financial initiatives can reverse a century of rising professional standards and make health care just another lean and mean downsizing industry.

After the U.S. Department of Veterans Affairs shut down research programs in its Greater Los Angeles Healthcare System (GLAHS) in March, the VA's undersecretary of health, Kenneth W. Kizer, realized that, rather than defending the facility's "failure to correct deficiencies," he would need to launch a reform initiative.

Is it appropriate for physicians to accept assisted-death requests at face value, or should they be interpreted as clinical indications of suffering? Should physicians act on patient requests to die, or should they address patient needs through other measures? Such are the difficult questions facing most physicians today.

What has happened to our nation since the 1960s and 1970s? The quest for racial equality appears to be rapidly dissipating. Blatant pre-civil rights racism has been replaced by a more virulent, yet camouflaged, form of racial bigotry.

Dual agency often presents a confusing situation for the clinician who must simultaneously serve two separate roles in a legal case, such as a treatment role and a forensic role (Berger, 1997). The two roles have different purposes, procedures, relationships with the patient or evaluee, and different ethical principles.

A few decades ago, ethics was widely understood in the professions to be a synonym for etiquette; it described the consideration that members of a profession showed to each other. More recently, it has come to refer to the rules governing the relationship between a professional and a client or patient.

The concept of a barrier between the blood and the brain arose in the late 19th century when the German bacteriologist Paul Ehrlich observed that certain dyes administered intravenously to small animals stained all of the organs except the brain. Ehrlich interpreted this to mean that the brain had a lower affinity for the dye than the other tissues. In subsequent experiments, one of Ehrlich's students injected a blue dye directly into the cerebrospinal fluid of rabbits and dogs. The dye readily stained the entire brain, but did not enter the bloodstream to stain the other internal organs.

At stake is whether the laws defining sanity can actually distinguish between those individuals who are evil and those who are mentally ill, and what role psychiatrists should play when the legal definitions make the difference between life and death. Also under the microscope is the value of forensic psychiatric testimony itself, and whether the message about mental illness is getting through to juries, judges and appellate justices.

Reducing the mandatory weekly monitoring of white blood cell (WBC) count during clozapine (Clozaril) treatment to a biweekly schedule after six months of treatment could result in twice the incidence of agranulocytosis and one death annually from blood dyscrasia in the approximately 67,000 patients using clozapine, according to testimony by Clozaril manufacturer, Novartis.

Unabomber - Poetry of the Times

Bestowed in gratitude in recognition of (his) superb, invigorating leadership of the American Psychiatric Association, his dedication to the principle that the highest quality patient care rests firmly on a true integration of the latest advances in psychodynamic and psychobiological thinking, and his strong advocacy for the scientific validation of what we do--all accomplished with his own consummate grace and elegance.

Despite expressed concerns by government agencies about the surplus of graduate physicians and residents, the net effect of the surplus is to restrain the growth of medical costs. For these reasons, until it can be proven that a physician surplus has negatively impacted patient care or until U.S. medical graduates cannot obtain medical positions, I do not anticipate a reduction of house staff positions.

"Can we talk?" asks a recovering patient who chastises psychiatry for too readily dismissing patients with her diagnosis as unable to benefit from talking therapy (A Recovering Patient, 1986). With managed care administrators quick to seize upon a lack of outcome data as a pretext for limiting treatment and a public mental health system pressed to handle caseloads as high as 200 to 300 patients per clinician, psychiatry's regrettable answer has often been: "No, we're too busy." Recent research findings, however, convincingly demonstrate that a flexible form of individual psychotherapy, when combined with appropriate neuroleptic medication, can yield improvements in social and vocational functioning unobtainable with "treatments as usual."

For over 50 years we clinicians have administered electroconvulsive therapy with little to guide us in deciding whether or not a particular induced seizure is an effective treatment. At first we thought that piloerection or pupillary dilatation predicted the efficacy of a seizure, but these signs were difficult to assess and were never subjected to controlled experiments.

The explosion of neuroscience developments in this "Decade of the Brain" now provides people with schizophrenia a new generation of antipsychotic therapies. For many, these medications (e.g., clozapine [Clozaril], olanzapine [Zyprexa], risperidone [Risperdal], and quetiapine [Seroquel]) produce an improvement over their "old" antipsychotics in terms of side effects and, for some, clinical response. For a select few, however, these medications can produce dramatic improvement, akin to what Sacks (1990) termed an "awakening." These medications create exciting opportunities to use psychotherapy, group work and rehabilitation with a population historically relegated to back wards or triaged to "case management."

Every year, more than half of newly approved drugs and biologics considered likely to be prescribed for children lack labeling information on safe and effective use. Seeking to rectify this situation, the FDA recently issued final regulations requiring new drugs and biologics that are therapeutically important for children or will be commonly used in children to have labeling information on safe pediatric use.