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.
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 Blatant pre-civil rights racism has been replaced by a more virulent, yet camouflaged, form of racial bigotry.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.
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.
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.
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.
The advent of safer psychopharmacological agents with less troublesome side effects, along with increasing knowledge of the broad array of syndromes treatable with medication, have led to a vast expansion in treatment options available to the psychiatrist. Studies and clinical experience demonstrate that employing psychotropic medication in combination with psychoanalysis or psychodynamic psychotherapy now occurs with increasing frequency.
Infant-caregiver interactions, seminal events in brain development and their possible relationship to later psychic vulnerability were explored in a recent continuing education seminar, "Understanding and Treating Trauma: Developmental and Neurobiological Approaches," at the University of California, Los Angeles.
Urging psychiatrists and other physicians to stay abreast of "what's going on in the youth culture," social psychologist Lloyd Johnston, Ph.D., explained that one of every 16 students entering high school has tried the potentially neurotoxic MDMA (Ecstasy) and among high school seniors, one-quarter are daily cigarette smokers and nearly one-third are frequent binge drinkers.
After a teenager's suicide attempt, her desperate and bewildered parents dragged her to a mental health clinic. The 16-year-old admitted to drinking nearly every day and using an assortment of other illicit drugs. Only after a month in treatment did the clinician learn that the teenager had been molested when she was 8 years old by an uncle and threatened with death if she ever told her parents.
The law and psychiatry are not disciplines that "fit together very easily," this is the essence of the debate that pervades psychiatry in death penalty cases. Ethical and moral issues faced by doctors practicing medicine clash with society's norms for ethical and moral behavior. At the same time, legal standards for insanity shift-often without regard to scientific advances or mental health advocacy.
The findings are disturbing. The Substance Abuse and Mental Health Services Administration (SAMHSA), in an effort to measure substance use and abuse among women, compiled data from its National Household Survey on Drug Abuse into a new report, Substance Use Among Women in the United States, which was released in September 1997. What they found is a worrisome indicator that substance use in this country is a significant problem for women, particularly among young girls ages 10 to 14.
Addicts are people who have learned how to give themselves a quick chemical fix or achieve an emotional high when they either want to or have to change how they feel, and when they want to ignore real-life problems. Most people do that, but the next morning, they feel sick or foolish. They don't do it again because it didn't work for them. What makes addicts different is that they are willing-or feel compelled-to do it again and again even though they "know" that doing so will get them into trouble.
The investigators reported that "all 30 men stated that their sexual desire had decreased considerably and that their sexual behavior had become easily controllable." These self-assessments were given credence by the investigators for not only being consistent with other measures, but because the subjects were voluntary participants who were not required to initiate or continue the treatment study as a condition for leaving jail or avoiding prosecution.
Nothing is sacred in America's pop culture. So when it embraces any topic, we've grown used to the relentless distortion that occurs, one that transforms reality into an odd combination of fact and fantasy.
There is a substantial constituency for alternative medicine. Worldwide, 70% to 90% of all health care "ranges from self-care according to folk principles, to care given in an organized health care system based on an alternative tradition or practice." As many as one-third of all Americans are reported to have some belief in alternative medicine or to be actively using nonmainstream remedies.
All families have such belief systems, which include expectations, values, attitudes-the basic assumptions-that govern family interactions. Because they determine the structure and organization of a family, the traditions they follow, the rules they abide by, and the values they hold, these beliefs shape the kinds of problems a family has and how they go about trying to solve them.
Previous research on the effects of early child care had led to controversy and confusion. The most provocative finding was that when infants were in nonmaternal child care 20 or more hours a week, starting in the first year of life, they were less likely than infants without such experience to form a secure emotional attachment to their mothers.
For elders confronted with the necessity of living in a nursing home, the choice of facility is a decision with profound consequences-for their health, their quality of life and their family finances. Nursing home care may cost $50,000 a year or even more, and more than half of all elders begin their nursing home stays by paying the costs out of pocket. That imposing sum can purchase excellent care, or can pay the rent for a place that is literally "worse than death" for the unfortunates who live there.
Recent headlines in national newspapers declaring that mentally ill patients are often denied care by psychiatric hospitals merely confirmed what most psychiatrists have known for years. A study published last December, however, created a stir when the authors released what they called "the first national analysis of the factors that promote or constrain economically motivated transfers of patients in relation to competitive pressures, hospital ownership, and managed care practices."
The stakes in the debate over recovered memories therapy ratcheted upward in October with the indictment of five health care professionals, including two psychiatrists, in Houston. Charged in a 60-count indictment-believed to be the first of its kind in the United States-the former staff members of the now defunct dissociative disorders unit at the Spring Shadows Glen Psychiatric Hospital are accused of perpetrating a "scheme to defraud by allegedly falsely diagnosing patients with multiple personality disorder caused by their alleged participation in a secret satanic cult."
The goals of National Coalition for Mental Health Professionals and Consumers are to educate the public about the problems of managed mental health care and to develop alternative health delivery models. I think greater media coverage has spawned greater awareness of the difficulties with managed care and has provided legislators with vital information. Certainly sharing their stories has made many people feel less alone and isolated within a system they find frustrating and depriving. I think media advocacy has helped doctors find support for their right to stand up to these abuses and band together in greater numbers to fight for integrity and quality in mental health care delivery.
In 1988 I was working as a general adult psychiatrist with a specialty in addictions. One day, a newly referred patient came to my office accompanied by his mother. Although he was well groomed, he was distinctly "nerdy." When I inquired about his chief complaint, his mother quickly explained that, although he had graduated from community college, he was unable to secure a job interview due to his obsessing on the details of his resume.
