Medication refusal and judicial activism: a reexamination of the effects of the Rivers decision.

OBJECTIVE: In 1986 New York State courts in Rivers v. Katz mandated judicial review of cases in which involuntarily hospitalized psychiatric patients formally refuse medications; previously only a clinical-administrative review was required. In an earlier study the authors found that formal refusals of medications declined significantly in the year after the Rivers decision and that length of time between refusal and its resolution increased. To determine whether these effects were maintained over time, data for the second year after the Rivers decision were examined. METHODS: Chi square analysis and analysis of variance were used to compare data from both a private and a state-operated hospital for the year before the Rivers decision with data from the first and second years after. RESULTS: The significant declines in the number of patients formally refusing medications were maintained in the second year after Rivers at both hospitals, as were the significant increases in the length of time to resolution. In the second year, judges continued to uphold the treating psychiatrists' recommendations. The decline in the refusal rates was not found to be part of a broader trend that had been manifest before the Rivers decision. CONCLUSIONS: The sharp decline in refusals resulted in fewer patients having their medications reviewed by others not directly involved in their care. Increased time to resolution has diminished quality of care and has resulted in increased patient decompensation and staff injuries.

Predictors of two-year outcome among psychiatric outpatients.

This study hypothesized that social competence and clinical factors previously associated with psychiatric outcome among inpatients would be effective predictors of outcome among outpatients (N = 77) as well. Intake and 2-year outcome status were assessed multidimensionally with absolute-level and residualized indices of functioning, overall clinical status, and symptomatology. Menninger health-sickness proved to be the best single predictor, although Phillips premorbid functioning, Strauss-Carpenter prognosis, social class, and diagnostic severity also predicted well to outcome. Patterns of associated predictor/outcome variable clusters were described. Results suggest that a general social competence factor predicts to psychiatric outcome across the entire range of disorders, but that life events stress does not.

Predictors of outcome among adult psychiatric first-admissions.

This study comparatively evaluated the prognostic potential of 10 demographic and clinical factors previously associated with psychiatric outcome. The longitudinal design employed intensive, structured, reliable interview techniques. One hundred forty-five subjects from a representative sample (N = 217) of community mental health catchment area first lifetime admissions were assessed at hospitalization and at 2-year follow-up. Predictors examined included premorbid functioning, overall health-sickness, diagnostic severity, social class, sex, age, IQ, race, and life events. Outcome was assessed multidimensionally with absolute-level and residualized indices of functioning and symptomatology. Phillips Premorbid Status and social class emerged from correlation and multiple regression analyses as the best predictors of functioning level and overall clinical status, while IQ was the most prominent indicator of symptomatology changes. Results support the notion that a general social competence factor predicts to psychiatric outcome across the entire spectrum of severe disorders.

Right to refuse treatment: impact of Rivers v. Katz.

This article examines the impact of the New York court decision, Rivers v. Katz, which in June 1986 dramatically changed the state procedure for responding to involuntarily committed psychiatric patients who formally refused psychopharmacologic treatment. The court rejected the medically administered review process that had been used to respond to involuntarily committed psychiatric patients who formally refused medication, and replaced it with a judicial determination of competent and "substituted judgment" provided by the court. Post-Rivers, the rate of patients consistently refusing treatment decreased, and the time from refusal to resolution increased. The clinical, legal, and economic implications of the Rivers procedure are discussed.

Psychiatric service utilization differences by sex and locale.

Underutilization of psychiatric services by men relative to women may reflect discrepancies between the male sex role in Western societies and the patient role. We hypothesize that this will be more important in a rural than a nonrural setting for two reasons. First, the relative lack of anonymity in a rural setting makes more evident incongruities between sex role conventions and actual behaviour. Second, because of the increased cultural heterogeneity of urban areas, traditional sex roles are less clearly delineated. These considerations suggest that the ratio of males to females receiving treatment in a rural setting should be lower than in a nonrural setting. It was found that for treated incidence the ratio of males to females was significantly lower in a rural than in a non-rural setting (p less than .01); for treated prevalence a lower male to female ratio was found in the rural than the nonrural setting, although this did not achieve statistical significance.

Life events and psychopathology severity: comparisons between psychiatric outpatients and inpatients.

Relationships between life events stress variables and seven indices of psychopathology severity for a group of 97 never-hospitalized outpatients were compared with those of a previously studied group of 217 first-admission functional disorder psychiatric inpatients from the same geographical catchment areas. The hypotheses tested were that degree of life events stress would be correlated positively with indices of psychopathological severity and that the magnitudes of association would be higher for the outpatients. Bivariate correlations and stepwise multiple regression with other potential demographic and prognostic moderator variables provided evidence for significant, but somewhat differing, patterns in outpatient vs. inpatient stress/pathology relationships. Contrary to prediction, the magnitudes of significant and near-significant associations between life events and pathology severity were not different in the two samples.

IQ as a prognostic indicator in adult psychiatric first-admissions.

This study used IQ, along with measures of premorbid adjustment, health-sickness, symptom level, diagnostic severity and demographic data, to predict to 2-year outcome measures of level of functioning, health-sickness, and symptoms for a sample of 145 adult psychiatric first-admissions. It was hypothesized that IQ as an indicator of cognitive ability, or of general ability to adapt, would predict positively to improvement over the 2-year period. Data analysis was conducted with bivariate correlations and multiple regressions, using both absolute-level and residualized outcome variables. IQ showed modest, significant relationships with all absolute outcome indices and six of seven residualized measures, especially for a subsample of those with non-average IQ scores. Regressions showed that IQ provided independent prediction of symptom outcomes.

Social class and psychiatric disorder. The examination of an extreme.

Relationships between social status and various aspects of mental disorder have been of long-standing interest to both clinicians and researchers, and a large body of literature exists attesting to the importance of social status in understanding psychiatric illness and disability. Reports examining social status and schizophrenia suggest that relationships between socioeconomic status and psychiatric illness may rest heavily upon differences between the lowest socioeconomic stratum and the remainder of society. To investigate the extent to which relationships between socioeconomic status and psychiatric illness and disability reflect differences between a deviant lowest socioeconomic stratum and the remainder of society, data from 217 patients hospitalized for psychiatric disorder and reassessed at a 2-year follow-up were examined. At initial assessment, 17 patient characteristics were found to be associated with socioeconomic status; for seven of these 17 characteristics, the largest difference between classes was found between the lowest and the adjacent (next-lowest) social class. At follow-up, for five of 15 characteristics found to be related to social class, the greatest interclass difference occurred between the lowest and the adjacent social class. Both initially and at follow-up, significant associations between patient characteristics and social class remained when the lowest social class patients were excluded from the analyses.

The prediction of relapse of schizophrenic patients using emotional data obtained from their relatives.

The capacity of anxiety and hostility outward scores derived from the content analysis of 5-minute speech samples from the relatives of patients to predict relapse or nonrelapse was tested in three distinct groups of schizophrenic patients. Significantly correct predictions were made which compared favorably to the predictive capacity of ratings obtained by means of the Camberwell Family Interview. The latter requires 1 to 2 hours to administer and about 1 hour to score, whereas the former method requires a tape-recorded 5-minute speech sample and up to 0.5 hour to score.

Social class and psychiatric outcome.

Although social status has been shown to relate to rates of certain types of psychiatric disorder and to treatment received, little information is available regarding social class and clinical improvement over time. This report presents findings from a prospective follow-up study of a representative sample of first-admission psychiatric patients. A variety of clinical characteristics were analyzed at hospital admission and 2-year follow-up. The social status of the individual patient, the social status of the patient's parents, and the social status associated with the patient's residential area were found to be correlated with improvement over the 2-year follow-up period.

Thiothixene induced edema.

The case described is of a woman who developed marked leg edema during thiothixene administration, and other cases of neuroleptic induced edema are reviewed. Possible mechanisms for the edema formation and clinical implications are discussed.

Sex and race of patients admitted for their first psychiatric hospitalization: correlates and prognostic power.

Much attention has been focused on the advantages enjoyed by white males in the general society. Are they similarly advantaged in a psychiatric population? Two hundred seventeen patients from two demographically heterogeneous catchment areas admitted to inpatient care during a 1-year period were interviewed using standardized procedures; 80% of the original sample was available for follow-up 2 years later. Race and sex showed no consistent pattern of relationships with psychiatric symptoms, disability, and outcome; being both white and male was not advantageous in terms of any of the characteristics examined.

A hostility measure for use in family contexts.

A modification of the Gottschalk-Gleser standardized instructions for eliciting speech samples was developed and tested in ongoing family studies. This modification, the Wynne-Gift technique, allows the interviewer to focus on the speaker's relationships with various family members. The usefulness and validity of the approach was assessed in a study of differences in attitudes toward the husband of 10 separated or divorced women as compared to the attitudes of 11 married women. Significant differences were found in the expected direction between mean hostility outward scores as well as hostility toward the spouse or ex-spouse of these two groups of women. The range of applications of this modification of eliciting speech samples is discussed.

Hysterical psychosis: an empirical approach.

Criteria for hysterical psychosis set forth by Hollender and Hirsch were systematically applied to a representative sample of 217 patients hospitalized for the first time in their lives for functional psychiatric illness. Surprisingly, no patients who met all of these criteria were found.

The severity of psychiatric disorder: a replication.

A prior report documented the importance of diagnosis and psychotic symptoms as components of a global rating of severity of psychiatric disorder. The availability of 2-year followup data on 174 (80%) of the original 217 patients permits examination of the stability of components of a global rating. Menninger Health-Sickness Rating Scale (MHRS) scores again correlated with diagnosis and with psychotic symptoms; unlike the initial report, followup MHRS ratings were closely associated with a depression-neurosis factor and social role performance. Age, race, and sex were independent of severity, while low socioeconomic status correlated with severity of illness.

Therapeutic milieu and clinical improvement.

While studies of the interpersonal environment of psychiatric hospitals have compared one ward or unit with another, there are no reports relating a patient's perception of a treatment unit to his clinical coruse on the unit. In this study conducted on an acute psychiatric ward of a general hospital, the Community Oriented Program Environment Scale (COPES) of Rudolph Moos was used as a measure of the patient's conception of an ideal ward and the patient's perception of the actual ward. The Nurses Observation Scale for Inpatient Evaluation (NOSIE) was used to rate psychopathology. Patient's perceptions of the actual ward, of an ideal ward, and differences between actual and ideal were not related to initial pathology or improvement over time. Research and clinical implications of these findings are discussed.