Capital versus noncapital murderers.

This study compares three groups of murderers: those who have received a death sentence (n = 18), those who were eligible to receive a death sentence but did not have it sought against them (n = 18), and those who were not eligible for the death penalty (n = 18). A retrospective record review of these 54 pretrial detainees in South Carolina who underwent court-ordered competency and criminal responsibility evaluations was completed comparing the following variables: age, race, marital status, educational level, prior legal history, relationship to the victim, race of the victim, existence of a codefendant, prior psychiatric history, psychiatric diagnoses, substance abuse history, use of substances at the time of the crime, Wechsler Adult Intelligence Scale (WAIS) or WAIS-Revised Full Scale IQ, and evidence of organic impairment. Statistically significant findings included race of the murderer, race of the victim, relationship to the victim, and existence of a codefendant. Death row inmates were more likely to be Caucasian and much more likely to have murdered a Caucasian than a non-Caucasian victim. Death row inmates were less likely to know their victims and more likely to have a codefendant. Psychiatric and organic findings did not differ among the groups, but the rate of organic findings and substance abuse was high in all three groups.

Alcoholism. Taking a preventive, public health approach.

Alcoholism is a common, chronic, often progressive disorder that has negative effects on a patient's health and severe consequences for society as well. A positive, public health approach that integrates medical, psychological, and social therapies can lead to improved outcomes for patients who abuse alcohol. Physicians can play an important role by educating patients to prevent alcohol abuse from starting, being alert to the risk factors, recognizing the signs of alcoholism (especially during its early stages), and initiating interventions designed to halt progression of this disease. Doctors should maintain a therapeutic stance with patients who have continued to abuse alcohol, even after frequent relapses. Consultation with alcoholism experts may be helpful when treatment is difficult or there is the possibility of a dual diagnosis.

AIDS and the family: implications for counselling.

The presence of HIV spectrum illness stimulates a powerful emotional reaction from a patient's family and friends. Grief and shock over the infection, and its implications are frequent observations. Sadness, anxiety, helplessness and anger are also common. Health care staff should address these responses in order to strengthen coping skills and maximize interpersonal comfort. Stigmatization and isolation are major stressors. Bereavement is complicated by fear, shame, dependency and hopelessness. Therefore, a task in counselling is to maintain the integrity and supportiveness of the patient's social unit by encouraging open communications between those involved and by educating about AIDS. Information should be provided on HIV transmission, self-protection, and illness progression as well as the safety of causal contacts and the practices of 'safer sex'. The significant others should retain outside interests and be encouraged to seek help for patients from supportive social agencies. Instillation of hope lends benefit to patient, family and friends. Kind, non-judgmental counselling and good quality medical care should be made available, especially since HIV-related disorders are increasingly becoming a chronic disease. Advocacy for the significant others translates into better adjustment and it enhances the patient's medical prognosis.

Psychostimulants for depression in the medically ill.

Medically ill patients who show signs of depression may have problems with traditional antidepressant therapy, because of the side effect profile and the delayed onset of action of these agents. Psychostimulants such as methylphenidate and dextroamphetamine are another treatment option. The beneficial effects of these drugs are usually noted within 36 hours, and drug habituation is generally not a problem. The primary obstacle to the use of these agents for depression in medically ill patients is the hesitancy of physicians to prescribe them.

Suicide attempts by the old and the very old.

Attempted suicide by the elderly is a major psychiatric problem. Ninety-five patients between 60 and 90 years of age were evaluated by a psychiatric consultation service after a suicide attempt. Characteristics of this group included (1) a high degree of premeditation, (2) a tendency toward firearm use and wounds to the head, (3) male sex, (4) coexisting medical problems, (5) serious intent that increased by decade, (6) solitary living arrangements, (7) presence or history of a major psychiatric illness, and (8) ill health reported as a precipitant to suicidality. Major depression was the most common psychiatric diagnosis, with congestive heart failure and chronic obstructive pulmonary disease the most frequently noted physical ailments. This elderly population of attempters resembled older persons who actually completed suicide and differed significantly from 1630 persons aged 16 to 59 years who attempted suicide. Heightened investigation of depressive features, treatment of alcohol abuse, early referral for psychiatric care, limited access to firearms, and strategies aimed at decreasing social isolation are recommended to decrease the likelihood of completed suicide in the elderly.

Patients who refuse heart transplantation.

Some terminally ill patients refuse proposed heart transplantation. Forty patients were offered this surgery; six (15%) declined. Candidates refusing surgery were likely to have a psychiatric diagnosis and heart disease longer than 1 year. Factors thought to influence the decision to refuse surgery included (1) depression, (2) ambivalence about surgery or survival, (3) previous negative experiences with surgery, (4) acceptance of the inevitability of death, (5) concerns about postoperative quality of life, (6) organic brain syndrome, and (7) denial of the severity of heart disease. Patient refusal of a heart transplant is often disconcerting for members of the transplant team.

Sexual concerns after heart transplantation.

Sexual concerns after heart transplantation are commonly experienced yet seldom voiced. Forty-five patients approved for this procedure were surveyed regarding sexual issues. Twenty-one (47%) persons responded, of whom 16 had undergone heart transplantation, and five were waiting for a donor. Sexual dysfunction included impotence, ejaculation problems, altered libido, and avoidance of sexual opportunities. Contributing factors to these sexual difficulties were fear of death during coitus, effects of medication on interest and ability to function, body-image concerns, depression, uncertainty about the sexuality of the donor, and altered roles and responsibilities within the family. Recommendations for members of heart transplant teams include (1) obtaining a routine sexual history during the evaluation of candidates, (2) heightening awareness of the sexual concerns of these persons, (3) aggressively treating clinical depression, (4) establishing peer support groups for spouses of transplant patients, (5) presenting didactic material on sexual issues after transplant, (6) adjusting medications when sexual problems arise, and (7) addressing one's own level of comfort in discussing sex-related topics with transplant patients.

Attempted suicide by black men and women: an 11 year study.

Two hundred and thirty-two black patients (103 men, 129 women) who attempted suicide were referred for psychiatric consultation from January 1976 through August 1987. Black male attempters were (1) more often schizophrenic; (2) more apt to be intoxicated; (3) more commonly psychotic; and (4) more prone to use violent methods. Black women were more likely to manifest clinical depression and much more inclined to choose drug overdose as a method. Women were also more apt to jump from buildings or bridges and deliberately set themselves ablaze. Referrals of suicide attempters increased for both sexes over the study period, and violent methods, particularly firearm use, rose steadily among black women over the 11 1/2 years. Recommendations for providing care to black suicide attempters include (1) appreciation of the psychological effects of racism; (2) increased sensitivity to depressive features in black schizophrenics; (3) consideration of affective disorders in young black males frequently involved in violent acts; and (4) awareness of one's own racially biased attitudes.

Psychiatric consultation for patients with self-inflicted gunshot wounds.

The study describes 260 persons referred over a 12-year period for psychiatric consultation after shooting themselves. The population consisted primarily of young, white men between the ages of 20 and 29. The abdomen was the most common site of injury for both sexes. Previous suicide attempts and past psychiatric histories were uncommon, but alcohol was involved in 25% of cases. Major depression and alcohol abuse were the most common psychiatric diagnoses. Tasks for the psychiatric consultant include dealing with reactions of hospital staff, instituting appropriate suicide precautions, determining future suicidality and psychiatric disposition, and helping patients cope with family reactions to the suicide attempt and with the psychological effects of disfiguring injuries.

What about mandatory AIDS testing?

Mandatory testing for AIDS is controversial. Such screening has been suggested for prisoners, immigrants, prostitutes, military personnel, and persons contemplating marriage or pregnancy. Quarantining and even tatooing have also been recommended for persons with AIDS. The advent of mass testing raises the issues of (1) proper allocation of scarce AIDS resources; (2) the need for confidentiality of examination reports; (3) the value of this assessment without the existence of a definitive treatment; (4) the possibility of both false positive and false negative results; and (5) the provision of counseling for people with positive testing. Other concerns involve public health needs versus individual rights, and the confidentiality of the doctor-patient relationship. Past epidemics serve as paradigms for the role of mandatory screening and quarantine in a public health crisis. As testing for AIDS is expanded, anticipate that adverse reactions such as panic, depression, grief, compulsive behavior, and suicide attempts will increase. The physician must provide counsel on such matters as "safe sex" practices, avoidance of needle sharing, and early warning signs of AIDS and ARC.

Stresses on physicians treating AIDS.

Psychologic issues for physicians treating AIDS include feelings of helplessness, discomfort with alternative lifestyles, fear of contagion and grief. Physician reactions may include unnecessarily heroic medical interventions, avoidance of the patients' families, injudicious use of narcotics, unwillingness to involve patients' homosexual partners in treatment decisions, anger at hospital personnel and colleagues, refusal to supervise medical students on AIDS cases, despondency and even resignation from employment.

Psychologic implications of AIDS.

Eleven patients with AIDS were seen by a psychiatric consultation service over a four-year period. Psychologic issues identified in these patients included changes in body image, feelings of helplessness and isolation, sexual concerns and the grief process. Management should be aimed toward maintaining a nonjudgmental stance, providing liaison with other caregivers and securing appropriate information and grief counseling for patients, with provision for the patient's loved ones.