Informing patients about tardive dyskinesia.

The effects of a formal (written) approach v an informal (oral) approach to obtaining informed consent for neuroleptic treatment were compared in 25 schizophrenic outpatients with tardive dyskinesia. Both groups had significant increases in knowledge, but only the informal/oral presentation group retained significant new knowledge at two-month follow-up. Overall, patients did not learn the information deemed most relevant for rational decision making about neuroleptic treatment. Younger patients started out with more knowledge and retained significant new knowledge at follow-up. All study patients remained in treatment and all but one remained on neuroleptic regimens. There was no increase in relapse or treatment noncompliance in the study population compared with a comparison group. While information about tardive dyskinesia can be safely disclosed to schizophrenic outpatients, such disclosure is evidently most meaningful when repeated informally in the context of a therapeutic relationship.

Pharmacotherapy of impaired affect in recovering schizophrenic patients.

BACKGROUND: Prominent and persistent anxiety, depression, and/or negative features characterize a substantial minority of recovered or residually psychotic schizophrenic outpatients and contribute to poor outcome. Because extrapyramidal side effects of typical neuroleptic medications often resemble such features, we first systematically studied the contribution of extrapyramidal side effects to these problems and their treatment. For patients who remained distressed, controlled trials of supplemental thymoleptics were undertaken. METHODS: In trial 1, 92 distressed (depressed and/or anxious) patients and 36 patients in a defect state (patients with negative symptoms) participated in a double-blind, intramuscular challenge that compared centrally acting benztropine mesylate with peripherally acting glycopyrrolate. In trial 2, 57 distressed patients and 22 patients in a defect state were randomly assigned to a double-blind, neuroleptic medication dose-reduction group. In trial 3, 57 chronically distressed patients who were maintained on a low dose of fluphenazine decanoate were randomly assigned to a supplemental desipramine hydrochloride, lithium carbonate, or placebo group under double-blind conditions for 12 weeks. RESULTS: For patients who were already maintained on antiparkinsonian medication, impaired affect was not resolved by additional benztropine. Only distressed patients with a family history of severe mental disorder (often affective) showed improvement with neuroleptic medication dose reduction. Patients in the defect-state group reported less dysphoria on a reduced neuroleptic medication dose, but negative symptoms persisted. Desipramine improved diverse aspects of mood and residual psychoticism, possibly as a prophylaxis against minor affective exacerbations. Depression improved in women only. Lithium positively affected multiple indexes of anxiety and anxious depression. CONCLUSION: Most often, persistent affective impairments are neither resistant extrapyramidal side effects nor characterological traits. Thymoleptics improve the nonphasic, chronic types of anxiety and depression in contrast to the acute, episodic forms, for which little support can be found in the literature.

Dose of fluphenazine, familial expressed emotion, and outcome in schizophrenia. Results of a two-year controlled study.

Issues regarding the side effects of antipsychotic medication and the possible contribution of the environment to dose requirements led to a two-year controlled dosage study of maintenance antipsychotic medication and familial environment among recently discharged schizophrenic patients. Seventy stable patients, living in high- or low-expressed emotion (EE) households, were randomized, double blind, to receive a standard dose of fluphenazine decanoate (average, 25 mg every two weeks) or a minimal dose representing 20% of the dose prescribed (average, 3.8 mg every two weeks). No differences in relapse were observed among dose, EE, or dose and EE. Patients in the minimal dose/high-EE condition experienced more minor but aborted episodes in year 2. Side effects were fewer on the minimal dose after one year, and low-EE patients were better adjusted than high-EE patients. Over time, minimal-dose recipients were significantly more improved in their instrumental and interpersonal role performance than were standard-dose recipients.

Screening for tardive dyskinesia.

A program of routine Abnormal Involuntary Movement Scale (AIMS) examinations is contrasted with a referral system for detection of tardive dyskinesia in an outpatient schizophrenia clinic. Routine clinical use of the AIMS examination may have improved the early detection of tardive dyskinesia, which could result in a decrease in the morbidity associated with this disorder. Routine AIMS examinations also facilitated repeat discussions with patients about tardive dyskinesia, which provide an opportunity to obtain ongoing informed consent for treatment with neuroleptics.

Modernization of a mental health act II: outcome effects.

The authors studied the effect of Pennsylvania's 1976 Mental Health Procedures Act on the hospital course of involuntarily detained patients. They found that more court hearings to extend commitment were requested, held and approved under the modern law. There was a decrease in the number of schizophrenic patients who signed in voluntarily. They found no change in the mean length of hospitalization under the new law whether patients were voluntary or involuntary. They found that patients did not often sign in voluntarily or go to court within the legally prescribed periods.

Minimization and overreaction to tardive dyskinesia.

Psychiatry's response to the risk of tardive dyskinesia (TD) from long-term neuroleptic drug use continues to swing from one extreme (overreaction) to the other (minimization or denial). The potential negative effects on psychiatric practice of these extreme responses are reviewed. We suggest that while concerns about litigation may partially account for the continued overreaction and minimization, a more fundamental explanation is psychiatry's continuing inability to integrate itself fully as a medical discipline. We suggest that four basic concepts about schizophrenia and its long-term treatment need to be accepted before TD can be responded to objectively: schizophrenia is a serious brain disease; neuroleptics are helpful when properly used; there are limits to the value of neuroleptic drugs in the treatment of schizophrenia; and neuroleptic drugs can cause serious side effects.

The scale for treatment integration of the dually diagnosed (STIDD): an instrument for assessing intervention strategies in the pharmacotherapy of mentally ill substance abusers.

The authors developed a series of 15 multiple-choice vignettes which pose common dilemmas in the pharmacotherapy of patients suffering from psychoactive substance use disorders coexisting with other mental disorders. Fourteen judges standardized the treatment options along a 'treatment integration continuum'. The authors surveyed 112 psychiatrists with the vignettes and 3 subscales of the Substance Abuse Attitude Survey. Ten of the 15 vignettes were taken to form the normally distributed Scale for Treatment Integration of the Dually Diagnosed (STIDD), which is described in terms of its reliability, validity and potential use as a teaching and research tool.

Documenting informed consent for treatment with neuroleptics: an alternative to the consent form.

Clinicians can comply with Ohio state regulations for documenting patients' informed consent for treatment with neuroleptic medication by checking a box in the medical record stating that a periodic discussion of informed consent has occurred and writing a note about the discussion in the narrative record. The authors discuss clinicians' experience with this alternative to the conventional consent form in a large community support agency. Although the approach has been largely successful, implementation has been hindered by some clinicians' incomplete understanding of the informed consent process. Continued training is needed to bring the ideal of informed consent into clinical practice.

The effectiveness of outpatient civil commitment.

The effects of outpatient civil commitment on community tenure and functioning were studied in a group of 20 patients with a history of recurrent hospitalizations, noncompliance with outpatient treatment, and good response to treatment. During the first 12 months of outpatient commitment, patients experienced significant reductions in visits to the psychiatric emergency service, hospital admissions, and lengths of stay compared with the 12 months before commitment. They significantly increased the number of appointments kept with their psychiatrist. It appears that when used judiciously, outpatient civil commitment is a helpful tool in maintaining hospital recidivists in the community.

Getting ready for recovery: reconciling mandatory treatment with the recovery vision.

Considering treatment of serious mental illnesses, it might appear that the recovery model would be incompatible with any form of mandatory treatment. The authors suggest that this is not so. With individuals whose psychotic illness substantially impairs decision making, mandatory treatment may offer the best hope of getting well enough for recovery to be possible. It is essential, however, that any program involving involuntary community treatment involves recovering individuals who have themselves experienced a serious mental illness. The authors propose the use of a consumer-run guardianship program and a capacity review panel as two possible ways to achieve such participation.

Informed consent and incompetent medical patients.

The mentally incapacitated patient is frequently encountered in the general medical hospital. Incapacity is the clinical state in which a patient is unable to participate in a meaningful way in medical decisions. Mentally incapacitated patients relinquish the authority, that is the competent patient's right, to choose among professionally acceptable alternative treatments. Such patients, therefore, require a surrogate decision-maker. There are certain clinical situations in which questions of incapacity are especially important to consider. In a study for the President's Commission for the Study of Ethical Problems in Medical Biomedical and Behavioral Research, the most common problem in recognizing incapacity was found with previously capable patients who became transiently incapacitated during the course of hospitalization. Questions of incapacity or the authority of surrogate decision-makers also arose with comatose, mentally retarded, mentally ill, and physically handicapped patients. While standards to determine capacity remain unclear, a practical approach is to demonstrate that a patient is able to describe the physician's view of the situation and to understand the physician's opinion as to the best intervention. When a patient is deemed to be incapacitated, the physician should turn to family members, whenever possible, to make decisions.