Limitations on psychiatrists' discretionary civil commitment authority by the Stone and dangerousness criteria.

The dangerousness-oriented commitment criteria of Massachusetts were compared with the paternalistic Stone model of commitment in an emergency setting. In a sample of 1062 patients, the Stone criteria were more restrictive than the dangerousness-oriented criteria; 91 patients were committable by the Stone model compared with 218 under the present statute. A second comparison of only those patients who refused treatment yielded similar findings--52 patients were committable according to the Stone criteria compared with 80 under the Massachusetts statute. The greater restrictiveness of the Stone criteria in each comparison was in large part the result of the requirement that the treatment decisions of the patient be incompetent; in the broader sample, the criterion of major patient distress had a comparable impact. A comparison of patients committable under both standards with those patients currently committable who would be excluded under the Stone standard revealed significant differences. The dually committable patients were more likely to be psychotic, to meet statutory criteria for grave disability, and to be diagnosed as manic. The implications of the findings are discussed.

A prospective, multicenter study of patients' refusal of antipsychotic medication.

Refusal of treatment with antipsychotic medication was studied prospectively in a sample of 1434 psychiatric patients admitted to four acute inpatient units in state-operated mental health facilities in Massachusetts during a 6-month period. Compared with a control group of patients who accepted prescribed antipsychotic treatment, the 103 patients who refused were older, of a higher social class, and less likely to have been prescribed antiparkinsonian medications. On admission, prior to refusal of medication, patients who refused were found to have significantly higher Brief Psychiatric Rating Scale scores than compliant patients and more negative attitudes regarding their hospitalization and past, present, and future treatment. Treatment refusal had negative effects on the hospital milieu and on the patient; refusers were more likely to require seclusion or restraint and had longer hospitalizations than treatment acceptors. Most refusal episodes ended with voluntary acceptance of treatment. In 23% of cases medications were discontinued. Only 18% of the sample reached formal, judicial review, and in every case that did, involuntary treatment was ordered. The policy implications of these findings are discussed.

Perceived coercion in mental hospital admission. Pressures and process.

BACKGROUND: Patients' perceptions of coercion in admission may affect their attitude toward subsequent treatment, including their inclination to adhere to treatment plans. This study looks at the determinants of patients' perceptions of coercion. METHODS: A sample of 157 patients admitted to a rural Virginia state hospital and a Pennsylvania community hospital were interviewed within 48 hours of admission about their experience of coming to the hospital. All subjects were 17 years or older. Diagnoses were diverse, and 42% were involuntarily committed. The interview gathered an open-ended description of the admission experience followed by a structured interview that included several measures. RESULTS: Perceptions of being respectfully included in a fair decision-making process ("procedural justice") and legal status were most closely associated with perceived coercion, and a significant relationship was found with perceived negative pressures, ie, force and threats. However, only procedural justice was related to the perception of coercion at both sites and with both voluntary and involuntary patients. CONCLUSIONS: Patients' feelings of being coerced concerning admission appears to be closely related to their sense of procedural justice. It may be that clinicians can minimize the experience of coercion even among those legally committed by attending more closely to procedural justice issues.

Head injury and marital aggression.

Of 31 consecutive male patients referred for evaluation of marital violence, 19 (61.3%) had histories of severe head injury. Although the relationship between child abuse and head injury did not reach an acceptable level of significance, it did indicate a trend toward a positive relationship. Alcohol abuse, reported by 48.4% of the sample, was significantly associated with head injury. Confirmation of biological etiologies in marital aggression would have implications for prevention and treatment.

An empirical comparison of the stone and dangerousness criteria for civil commitment.

Massachusetts civil commitment criteria were compared in an emergency setting with a set of criteria developed by Dr. Alan Stone. Contrary to expectations, the Stone criteria proved to be more restrictive in a sample of 503 patients. Few patients would be newly committable under the Stone criteria; of the 35 patients committable under the Stone standard, 32 also met the current Massachusetts criteria for commitment. The clinical and policy implications of the adoption of the Stone criteria are discussed.

Prospective study of patients' refusal of antipsychotic medication under a physician discretion review procedure.

OBJECTIVE: The authors examined the refusal of antipsychotic medications and associated outcomes prospectively in a group of 348 psychiatric patients admitted to three acute inpatient units in a state-operated mental health facility in Virginia where psychiatrists have the discretionary power to administer treatment over patients' objections. METHODS: Newly admitted patients were administered both a questionnaire to ascertain their attitudes toward admission and the Brief Psychiatric Rating Scale (BPRS). Patients who refused antipsychotic medication were identified, and data were collected on the length of refusal and whether the refusal episode was terminated voluntarily or involuntarily. A group of patients compliant with antipsychotic medication was selected for comparison on outcome measures, including the rate of seclusion and restraint and length of hospitalization. RESULTS: Patients who refused treatment were found to have significantly higher BPRS scores than were patients who complied with antipsychotic treatment and more negative attitudes toward hospitalization and past, present, and future treatment. Refusal episodes were brief, on average 2.8 days, and all patients, who refused treatment were treated. When compared with the compliant patients, patients who refused treatment were more likely to be assaultive, were more likely to require seclusion and restraint, and had longer hospitalizations. CONCLUSIONS: Psychiatrists exercised their discretion to promptly treat all patients who refused treatment. Nonetheless, these patients suffered more morbidity than compliant patients. This study suggests that the negative sequelae of in-hospital treatment refusal cannot be eliminated by rapid treatment. The policy implications are discussed.

Patients' revisions of their beliefs about the need for hospitalization.

OBJECTIVE: An influential rationale for involuntary hospitalization is that prospective patients who refuse hospitalization at the time it is offered are likely to change their belief about the necessity of hospitalization after receiving hospital treatment. The authors examine how patients changed their evaluations of psychiatric hospitalization following hospital treatment. METHOD: The authors studied 433 patients who were interviewed about their hospitalization within 2 days of their admission to a psychiatric hospital; 267 of these patients were reinterviewed 4-8 weeks following discharge. RESULTS: When reinterviewed at follow-up, 33 (52%) of 64 patients who said at admission that they did not need hospitalization said that, in retrospect, they believed they had needed it. Only 9 (5%) of 198 patients who said at admission that they needed hospitalization shifted to saying that they had not needed it. CONCLUSIONS: Many of the patients who initially judged that they did not need hospitalization revised their belief after hospital discharge and reported that they had needed hospital treatment. However, perceptions of coercion were stable from admission to follow-up, and patients' attitudes toward hospitalization did not become more positive. Coerced patients did not appear to be grateful for the experience of hospitalization, even if they later concluded that they had needed it.

Factual sources of psychiatric patients' perceptions of coercion in the hospital admission process.

OBJECTIVE: The purpose of this study was to determine what predicts patients' perceptions of coercion surrounding admission to a psychiatric hospital. METHOD: For 171 cases, the authors integrated data from interviews with patients, admitting clinicians, and other individuals involved in the patients' psychiatric admissions with data from the medical records. Using a structured set of procedures, coders determined whether or not nine coercion-related behaviors occurred around the time of admission. Correlation and regression analyses were used to describe the predictors of patients' scores on the MacArthur Perceived Coercion Scale. RESULTS: The use of legal force, being given orders, threats, and "a show of force" were all strongly correlated with perceived coercion. A least squares regression accounted for 43.3% of the variance in perceived coercion. The evidence also suggested that force is typically only used in conjunction with less coercive pressures. CONCLUSIONS: Force and negative symbolic pressures, such as threats and giving orders about admission decisions, induce perceptions of coercion in persons with mental illness. Positive symbolic pressures, such as persuasion, do not induce perceptions of coercion. Such positive pressures should be tried in order to encourage admission before force or negative pressures are used.

A case of Tourette's syndrome with symptoms of attention deficit disorder treated with desipramine.

Therapy for Tourette's syndrome with tricyclic antidepressants has had varied results. Previous reports have not addressed the frequent association of symptoms of attention deficit disorder (ADD) with Tourette's syndrome or the plasma levels of tricyclic antidepressants. A boy with Tourette's syndrome and ADD-like symptoms was treated with desipramine, and all the symptoms improved. This drug may be effective therapy for patients with Tourette's syndrome and ADD-like symptoms.

A family study of patients with attention deficit disorder and normal controls.

In a family study of Attention Deficit Disorder (ADD), we collected data on first-degree relatives of 22 children with ADD and 20 normal children. The morbidity risk for ADD was 31.5% in the first group. This was significantly higher than the rate of 5.7% in the control group. Relatives of ADD probands were also shown to be at higher risk for Oppositional Disorders and Major Depressive Disorder (MDD). The findings indicate that ADD is a familial disorder associated with increased familial risk of other psychiatric disorders.

Head injury in partner-abusive men.

Research into etiology of marital aggression has focused primarily on psychosocial, political, and cultural factors, to the exclusion of physiological influences. Fifty-three partner abusive men, 45 maritally satisfied, and 32 maritally discordant, nonviolent men were evaluated for past history of head injury, by a physician who was not informed of group membership and aggression history. Logistic regressions confirmed that head injury was a significant predictor of being a battered. The implications of these findings for both marital aggression and post-head injury rehabilitation are discussed.

Head-injured males: a population at risk for relationship aggression?

Several recent studies suggest that head injury may be a potentially useful factor in explaining some types of aggressive behavior. In our research, we have been able to demonstrate an association between head injury and marital aggression using a sample of male batterers and appropriate comparison groups. Anecdotal and empirical literature also supports the hypothesis that aggression, relationship problems, and negative changes in personality and behavior are common sequelae to a head injury. This article explores the hypothesis that flows intuitively from the above, namely, that head-injured males are at increased risk for physical aggression in their intimate relationships. Empirical data are presented identifying several risk factors for relationship aggression and marital discord that may be sequelae of a significant head injury. Nevertheless, head-injured men were not found to be more physically aggressive with their female partners. The implications of these results are discussed.

The MacArthur Adjudicative Competence Study: a comparison of criteria for assessing the competence of criminal defendants.

A set of measures assessing competence-related abilities was administered to three groups of criminal defendants: a group committed for restoration of competence, a group identified by jail personnel as mentally ill but not incompetent, and a group without identified mental disorder. Data from this study were used to test key assumptions bearing on the legal criteria for adjudicative competence. The data show that among defendants able to understand the nature and purpose of the criminal proceedings, a significant proportion have an impaired ability to appreciate their situations as criminal defendants or to communicate relevant information to counsel; among defendants able to understand the proceedings and to assist counsel, a significant proportion have impaired decision-making abilities; and among defendants able to understand the nature and consequences of decisions to plead guilty or waive a jury, a significant proportion have impaired abilities to appreciate the significance of these decisions or to rationally manipulate information pertinent to making them. These findings highlight the importance of disaggregating the components of adjudicative competence.

The competence-related abilities of women criminal defendants.

A new research instrument, the MacArthur Structured Assessment of Competencies of Criminal Defendants (MacSAC-CD), was administered to three groups of women defendants: those adjudicated incompetent and committed to forensic hospitals for treatment (n = 38), jail inmates receiving mental health treatment (n = 18) who had not been adjudicated incompetent, and randomly selected jail inmates (n = 50). Measures of the competence-related abilities of understanding and reasoning were found to have satisfactory indices of internal consistency (coefficient alpha), and all measures correlated in the expected direction with measures of global psychopathology, psychoticism, and verbal cognitive functioning. Between-group mean scores were all in the expected direction and were statistically significant for four of seven measures. No differences in MacSAC-CD performance were found in comparisons of male and female defendants who had been adjudicated incompetent, nor were differences found in the performance of male and female jail inmates.

On being 'too crazy' to sign into a mental hospital: the issue of consent to psychiatric hospitalization.

This article examines the notion of informed consent to psychiatric hospitalization. While dicta in a recent U.S. Supreme Court decision, Zinermon v. Burch, has stimulated considerable interest in applying informed consent to psychiatric hospitalization decisions, there are no extant cases that define the contours of the doctrine in the hospitalization context. The potential scope of disclosure and the level of decision-making capacity sufficient for valid consent are examined. A model of consent to admission recommended by the American Psychiatric Association Task Force on Consent to Voluntary Hospitalization is critiqued.