The right to refuse psychiatric treatment.

The right to refuse psychiatric treatment has become an important clinical and legal issue in the last twenty-five years. This article briefly reviews the clinical, administrative, and legal aspects of the right to refuse psychiatric treatment, especially medication. Emphasis is placed on the clinical issues including the reasons for treatment refusals, and the management of treatment refusal. Empirical data are provided to illustrate the rights driven and treatment driven models of involuntary psychotropic medication administration.

Toward the development of guidelines for the conduct of forensic psychiatric examinations.

Guidelines for conducting forensic psychiatric consultations and evaluations have not been clearly established. The authors offer and discuss such guidelines, which are based upon the boundary guidelines in general psychiatric practice, ethics principles in general psychiatry, ethics principles in forensic psychiatry, and the relevant case and statutory law. These guidelines are intended to assist the psychiatrist in appropriately conducting forensic evaluations whether in litigation or administrative proceedings.

Homicidal behavior and sleep apnea: a case report and medicolegal discussion.

This case report documents the use of sleep apnea as a criminal defense for a man who fatally shot his wife during his usual sleeping hours. The defendant, who had severe sleep apnea as determined by a clinical evaluation and a polysomnographic study, admitted to shooting his wife but claimed that he was asleep at the time. Two physicians testified for the defense that the sleep apnea was of sufficient severity that the defendant may have had a confusional arousal related to the sleep apnea in which he could have shot his wife accidentally. Another physician, testifying for the prosecution, found no evidence to support this defense after a review of the patient's history and polysomnographic records and a review of relevant literature which may have linked sleep apnea with sleep-related violence. In this case, there was substantial apparent motive for the murder, including a past history of spousal and child abuse and a note written by the victim around the time of the shooting describing her intention to take the children and leave the suspect. The jury rejected the sleep apnea defense, handing down a first-degree murder verdict. In the discussion, we briefly review medicolegal issues related to the case as well as prospective guidelines for the medicolegal assessment of future cases.

Confidentiality of patient-related information.

Confidentiality is one of the cornerstones of the physician-patient relationship. Patients expect that their health care will be kept confidential, and the physician's legal and ethical responsibilities mandate this. Nevertheless, important, countervailing societal interests require that confidentiality be sacrificed under some circumstances. Patients, too, have legitimate access to their health care information. Familiarity with legal and ethical aspects of confidentiality will facilitate patient care and help protect the physician against allegations of breach of the patient's confidentiality.

A prospective comparison of four insanity defense standards.

OBJECTIVE: Controversy about the formulation of the insanity defense has been intense, but little empirical work is available regarding how different standards affect court findings. The major aims of the present study were to determine if different standards for determining insanity produced different judgments and to provide a broad descriptive picture of those cases in which the standards appeared to make a difference. METHOD: Four forensic psychiatrists were asked to indicate whether they thought 164 defendants met any or all of four insanity tests: 1) the American Law Institute (ALI) cognitive criterion, 2) the ALI volitional criterion, 3) the APA test, and 4) the M'Naghten rule. RESULTS: The four psychiatrists determined that 97.5% of the defendants met the ALI volitional criterion, 73.9% met the APA criterion, 70.3% met the M'Naghten rule, and 69.5% met the ALI cognitive criterion. Nearly two-thirds of the defendants met all four insanity tests, and 24.4% met only the ALI volitional test. Few defendants met cognitive tests without also meeting the ALI volitional test. Elimination of the volitional test for insanity reduced the rate of psychiatric recommendations of acquittal by 24.4%. CONCLUSIONS: These findings highlight the fact that the primary logical division between volitional and cognitive standards appears to be powerful but that distinctions between types of cognitive standards are not terribly powerful. In addition, the variation among individual raters must be viewed as an important determinant of how any insanity standard is applied.

Emotional and cognitive dysfunction associated with medical disorders.

The Beck Depression Inventory (BDI), General Health Questionnaire-30 (GHQ-30) and the Mini Mental Status Examination (MMSE) were administered to 335 randomly selected hospitalized medical patients. Thirty-six percent showed depressive symptomatology as measured by the BDI, 61% showed emotional dysfunction on the GHQ-30, and 28% evidenced cognitive dysfunction on the MMSE. Each patient's medical status was described according to 13 disease categories. Patients with neurological, respiratory, and bone and connective tissue disease had the most cognitive dysfunction on the MMSE. Patients with cancer and bone and connective tissue disease had the greatest amount of emotional dysfunction as measured by the GHQ-30. Patients with gastro-intestinal disease, cancer, and bone and connective tissue disease had the greatest amount of depressive symptomatology. For cancer, this increased depressive symptomatology is the result of a higher number of somatic but not affective and cognitive symptoms on the BDI. Interview based data is needed to confirm these preliminary findings.

Informed consent and tardive dyskinesia.

Tardive dyskinesia presents a variety of problems and dilemmas to mental health professionals who treat the seriously mentally ill. Of utmost concern is the significant prevalence of this disorder in the chronically mentally ill, in conjunction with the continuing need of these patients for antipsychotic medication. Doubt about the ability of seriously mentally ill individuals to meaningfully participate in the informed consent process has been raised. Nevertheless, it is reasonable to expect mental health professionals to attempt to engage a mentally ill patient in the informed consent process, although there is uncertainty about the timing and manner of this effort. Several strategies to maximize patient understanding of the risks of antipsychotic medication can be used. The clinician who fails to do so risks liability for failure to obtain informed consent to treatment, which has been adjudicated in some cases.

The psychiatrist as legal guardian.

Most discussions about legal guardianship pertain to special populations, such as the mentally retarded or demented. Except for the case of refusal of antipsychotic medication, little has been written about using guardianship to authorize nonemergency treatment for a person who is mentally ill and treatable. The authors present several cases in which a consulting or administrative psychiatrist served as a temporary guardian for a hospitalized patient's personal affairs. The psychiatrist-guardian authorized diagnostic procedures or ECT for the temporarily incompetent patient and was then discharged as guardian. The authors discuss the problems and limitations of such a role for the psychiatrist.

Disposition of insanity acquittees in Illinois.

Little attention has been paid to the processing of insanity acquittees subsequent to criminal trial. This study first obtained descriptive data on new insanity acquittees (N = 137) in Illinois between January 1982 and July 1984 and then examined the criminal commitment criteria used by evaluating psychiatrists and criminal courts in the disposition of insanity acquittees. Acquittees in Illinois were largely male, chronic schizophrenics who had been acquitted for murder or attempted murder. Judges tended to use criminal criteria that were more demanding than those which had been recommended by psychiatrists. Stepwise discriminant analyses revealed that psychiatric diagnosis was the most influential factor in determining psychiatrists' recommendations and court dispositions. Psychiatrists and committing judges failed to comply with the requirements of the committment law in one quarter of the cases.

The amobarbital interview.

In two apparently disoriented patients, the emergency physician's use of amobarbital quickly eliminated diagnoses of an organic etiology. Although thousands of amobarbital interviews have had no complications, the use of amobarbital should follow a thorough evaluation. The amobarbital interview is a safe and simple technique to discriminate functional from organic illness, thus avoiding unnecessary medical and surgical treatment, neglected illness, and inappropriate disposition.