Developing the language of futility in psychiatry with care.

In psychiatric practice, treatment success is, in many instances, not an achievable goal. Psychiatrists may often not acknowledge treatment failure in their patients and seldom consider that patients may be in situations that share similarities with end-of-life dilemmas in general somatic medicine. In such instances, futile treatment may be continued and patient suffering may be prolonged. Doctors should play a leading role in patient education, diagnosis, promoting best treatment options, motivation and support, but patients should be given the opportunity to take ownership of their illness and their future. In the discipline of psychiatry, physician-assisted suicide may be an option but warrants careful consideration. Contemporary psychiatrists may act paternalistically, refusing to accept the limitations of their scientific skills and/or struggle with the moral good of 'letting go' when required. It is arguably the seeming complexity of gauging patients' understanding (competency, capacity) to make informed decisions that perpetuates futile treatment. Most patients, even in the presence of ongoing serious psychiatric illness, are able to give consent. Psychiatrists should be aware of the difference between being alive and living. Ongoing suffering cannot be condoned. The personhood of every patient and his/her bio-psycho-social and spiritual needs should, as far as possible, be respected. Psychiatrists should embrace the realisation of treatment futility and, in some cases, end-of-life decisions and take on the challenge as well as the responsibility of serving patients with mental illness in the best way possible.

Pharmacological challenge with a serotonin 1D agonist in alcohol dependence.

BACKGROUND: Both animal and clinical studies have implicated serotonergic dysfunction in the pathogenesis of alcohol abuse and dependence. However the exact mechanisms involved remain unknown. Theoretically, low serotonin promotes alcohol seeking behavior. Sumatriptan is a serotonin1D agonist. It is postulated that sumatriptan's agonism at this terminal autoreceptor increases negative feedback, creating a net effect of decreased serotonergic neurotransmission. Administration of sumatriptan should therefore produce a craving for alcohol and the desire to drink. METHODS: Fifteen patients with alcohol dependence who had undergone detoxification were recruited. Sumatriptan (100 mg) and placebo was administered in cross-over fashion on 2 separate days 72 hours apart. Both patients and raters were blind to all treatments. Patients were assessed on the following scales at -30, 0, 30, 90, 150 and 210 minutes: A 6-item scale designed to rate the patient's intention to drink; The Sensation Scale; a 13-item affect analog scale designed to rate the pattern and extent of emotional changes; and an 8-item scale designed to rate the patient's craving for alcohol. RESULTS: No significant differences were found between the placebo and sumatriptan groups and no significant cross over effects were found. CONCLUSION: The general lack of efficacy of sumatriptan in producing alcohol-like symptoms or a desire to drink alcohol may suggest that the 5HT1D receptor plays little role in the pathophysiology of alcoholism.