Effects of treatment and alternative care on length of stay on a general hospital psychiatric unit--results of an audit.

Quality controls are becoming an important part of our health care system. A medical audit is one way of evaluating quality of care, and this paper describes the results of an audit conducted to investigate the reasons for a prolonged stay on a psychiatric inpatient unit. The results showed a decrease in the mean length of stay over a five year period, although the figure remained substantially above provincial norms. A review of the hospital charts of a random sample of one in six patients whose hospital stay exceeded 30 days was carried out. It revealed that in 50.0% of cases the reasons were "medically acceptable," in 10.3% the reasons were "medically unacceptable" and in 39.7% the reasons were "social and administrative" and beyond the control of the treating psychiatrist. The implication of these results are discussed.

Major affective disorders and forensic psychiatry.

Major mental illnesses, such as major affective disorders and schizophrenias, form a relatively small diagnostic group among mentally disordered offenders. The major affective disorders are less common when compared with schizophrenics among such offenders. Yet, some of the most violent crimes, such as murder, attempted murder, and serious assaults, especially intrafamilial violence, are committed by major affective disorder patients. The offenses by this group of patients are committed while suffering from active symptoms of the illness. As such, a substantial majority is not considered fully criminally responsible for the offense. Many such offenders are found not guilty by reason of insanity and are sent to psychiatric hospitals.

Interface between mental subnormality and law--a review.

In this two-part paper, the authors present a review of various facets of the interface between mental subnormality and law. Part I deals with the historical evolution of the concept and definition of mental subnormality, both in the medical and in the legal field, and also the civil issues concerning the mentally subnormal, such as education, employment and community living, marriage, parenthood and involuntary sterilization, the right to treatment and the right to refuse treatment, guardianship and mental incompetency. Part II deals with the criminal issues involving the mentally subnormal, such as the relationship between mental subnormality and crime, competency to stand trial and criminal responsibility, as these concepts relate to the mentally subnormal, and the mentally subnormal in correctional institutions. The emphasis is on the North American scene, that is on the developments in the services for the mentally subnormal in the U.S.A. and Canada. The important judicial and legislative decisions that had great impact on the rights of the mentally subnormal in civil and criminal areas, are covered in this review. The dynamic nature of societal standards and attitudes is also reflected in the ways it deals with the underprivileged members, such as the mentally subnormal. The judicial and legislative decisions thus reflect these changes in societal attitude. As such we can expect ongoing revisions in the services for the mentally subnormal and enactment of new provisions to protect their interests in institutions and in the community.

The clinical and forensic psychiatric issues of retifism.

The literature on the etiological theories, clinical manifestations and treatment of retifism (foot fetishism) and fetishisms in general are briefly reviewed. The case of a 27 year old married male foot-fetishist is presented with emphasis on the psychosexual development leading to the specific sexual deviation. The specific behavioural treatment consisted of covert aversive conditioning using self-reports of sexual urges and psychophysiological monitoring as objective measures of therapeutic change. The theoretical basis for the therapeutic response is discussed.

ECT in an acutely psychotic pregnant woman with actively aggressive (homicidal) impulses.

The specific use of ECT to control homicidal impulses in a pregnant, acutely psychotic schizophrenic patient is described, with no adverse effects to the mother or the baby. Besides the relative safety of the procedure during pregnancy, the need for monitoring foetal effects is stressed. Although literature is abundant on various aspects of ECT (1-3) there has been little written on its use in pregnancy (4-6) for its value in treating severe depressive illness or certain types of schizophrenia; without adverse effect to the mother and the baby, and where there is a risk-benefit advantage to its use. Nineteen hundred and eighty-four marked 50 years in the history of the use of convulsive therapy (Metrazol) since its introduction into the realm of psychiatry by the Hungarian psychiatrist, Ladislas Meduna. Electro-convulsive therapy (ECT) has been the subject of much controversy among the lay public and some professionals alike in recent years, even though it is generally considered to be one of the most effective treatments available in psychiatry. The Canadian Psychiatric Association (7), the American Psychiatric Association (8), and the Royal College of Psychiatrists (U.K.) (9) have made their position clear on the issue. In a recent Canadian survey of the use of ECT, Smith concluded, "Some of the reported rates are below the predicted minimum levels" indicating that "certain patients have been deprived of the most effective treatment available" (10).