The state of electroconvulsive therapy in Texas. Part 2: contact with physicians, hospitals, medical liability insurance companies, and manufacturers of stimulus generating equipment

Since mid-1993, all ECT treatments performed in the state of Texas (except for United States government hospitals) must be reported every quarter to the Texas Department of Mental Health and Mental Retardation (TXMHMR) on a data collection form provided by the Department. Part 1 of this paper reviewed that data. This paper reviews the responses to questionnaires and contacts made with physicians, hospitals, medical liability insurance companies, and manufacturers of stimulus generating devices regarding their experience with ECT in Texas. Questionnaires were sent to physicians and hospitals that had not performed ECT during the final two quarters of the review period. Medical liability insurance companies and the manufacturers of the stimulus generating equipment used in ECT were contacted regarding their experience with liability claims. The results indicate that medical liability in regards to the performance of ECT is extremely low. Physicians and hospitals that stopped performing ECT did so for reasons other than medical liability.     

Federal influence on state health policy

This paper reports on research that was intended to demonstrate the impact of federal programs on state health policy goals. The sample included four Public Health Service programs (Health Planning and Resources Development, Nurse Training, Cooperative Health Statistics and the Community Mental Health Centers program) in six states (Colorado, Maryland, Michigan, Oregon, South Carolina, and Texas). The authors conclude that, in general, states' political environments tailor program implementation to suit state preferences.     

A profile of mentally disordered offenders admitted to inpatient psychiatric services in the United States

This research note presents data about mentally disordered offenders (MDOs) treated in inpatient psychiatric services. Data are derived from 1980 admission surveys by the Survey and Reports Branch, National Institute of Mental Health (NIMH). These data report for the first time inpatient services provided to MDOs by non-Federal general and private hospitals. A total of 31,773 MDOs were admitted, with 85% going to state and county mental hospitals. The largest group, including admissions for evaluation, was ISTs (58%), followed by mentally disordered prisoners (32%), NGRIs (8%), and MDSOs (3%). Women and whites tended to be overrepresented among MDOs as compared to prison and jail inmates. Clear diagnostic differences by legal status were found, with schizophrenia predominant among NGRIs (81%) and alcohol and drug abuse disorders more frequent among ISTs. Overall, state and county hospitals in both 1967 and 1980 were the primary locus of care for mentally disordered offenders.     

Informed consent in the electroconvulsive treatment of geriatric patients.

The past 15 years have been marked by an increasingly stringent regulatory atmosphere regarding the administration of ECT, leading to delays in treatment and declines in usage. Regulatory changes requiring judicial intervention in clinical decisions are driven by the notion that only the courts can provide adequate due process protections when legal rights and clinical need conflict. We retrospectively reviewed the documentation of the informed consent process for 62 geriatric patients receiving ECT to assess the degree to which clinicians conformed to the spirit of the informed consent doctrine in a state that allows significant clinical discretion in decisions to administer ECT to patients lacking decisional capacity. In the eight cases in which the patient's decisional capacity was questioned, we found appropriate documentation of the patient's failure to comprehend his condition or the proposed treatment, evidence of a high degree of family involvement in decision making, and extensive use of outside consultants to document decisional incapacity and the need for treatment. Evidence of family participation in decision making was present for a high percentage of cases in which decisional capacity was unquestioned. Our review demonstrated high compliance with the procedural safeguards contained in the state regulation and with the spirit of the informed consent doctrine.     

The use of harmful to others-criterion for involuntary treatment in Finland

During the past decades the Western countries have paid attention to their Mental Health legislation, in particular, by making changes concerning involuntary treatment. In Western countries legislation allows involuntary treatment of the mentally ill. Involuntary psychiatric treatment is motivated by either potential harm to others (for the good of society) or by need for treatment and/or potential self-harm (for the good of the patient). The aims of this study were to describe to what extent the danger to others criterion is used as a motivation for involuntary hospitalization and detainment in Finland, and to what kind of patients this criterion is applied. The study involves a retrospective chart review of all the treatment periods of a six month admission sample in three Finnish university hospitals. We found that potential harm to others has been rarely used as a motivation for involuntary referral or detainment together with other motivations, and virtually never as the sole motivation. With the exception of gender, which was most often male, patients with potential harm to others did not differ significantly from other involuntarily treated patients. Coercion (defined as seclusion, the use of restraints, forced medication, physical restraint or restrictions in leaving the ward) was not used with these patients more regularly than with the patients motivated by the other criteria. Length of stay (LOS) in a psychiatric hospital did not differ between the patients determined harmful to others and the other involuntarily treated patients.     

Psychological models of mental disorder, human rights, and compulsory mental health care in the community

Recent amendments to the 1983 Mental Health Act in the UK (Mental Health Act 2007) include the controversial provision for: “supervised treatment in the community for suitable patients following an initial period of detention and treatment in hospital”. This provision is widespread, and more formal, in other English-speaking jurisdictions. Reviews of the international literature, human rights considerations and the perspective of psychological approaches to mental health care suggest that proposed ‘supervised community treatment orders’ are valuable, lawful, and compatible with the European Convention on Human Rights if certain specific conditions are met. Provisions for ‘supervised community treatment orders’ in the UK should be supported, but with the provisos that: the powers of the Mental Health Act are limited as in Scotland, to persons whose “ability to make decisions about the provision of [care] is significantly impaired”, that each order is time-limited and subject to review by a properly constituted Tribunal, and that the use of such orders should represent a benefit to people in terms of more appropriate treatment, or be a least restrictive alternative, or better preserve the person's private and family life.     

Measuring motivation to change in offenders

Abstract

Measuring motivation to change in offender populations is important both for selection into treatment programmes and for assessing progress in therapy. Two studies are reported in this paper, both looking at the psychometric properties of questionnaires designed to measure stage of change in therapy. The samples used were patients detained in special hospitals under the Mental Health Act (1983) classification of psychopathic disorder. The first study provides norms for this group on the stages of change in psychotherapy questionnaire, plus some additional information on its relationship with self-esteem and self-efficacy measures. The second study looked at a brief version of the stages of change questionnaire, concluding that its psychometric properties were such that further use was contra-indicated.     

Medical examiner/coroner records: uses and limitations in occupational injury epidemiologic research

Epidemiologic research often relies on existing data, collected for nonepidemiologic reasons, to support studies. Data are obtained from hospital records, police reports, labor reports, death certificates, or other sources. Medical examiner/coroner records are, however, not often used in epidemiologic studies. The National Institute for Occupational Safety and Health's Division of Safety Research has begun using these records in its research program on work-related trauma. Because medical examiners and coroners have the legal authority and responsibility to investigate all externally caused deaths, these records can be used in surveillance of these deaths. Another use of these records is to validate cases identified by other case ascertainment methods, such as death certificates. Using medical examiner/coroner records also allows rapid identification of work-related deaths without waiting several years for mortality data from state offices of vital statistics. Finally, the records are an invaluable data source since they contain detailed information on the nature of the injury, external cause of death, and results of toxicologic testing, which is often not available from other sources. This paper illustrates some of the ways that medical examiner/coroner records are a valuable source of information for epidemiologic studies and makes recommendations to improve their usefulness.     

强制治疗精神疾病患者的程序法研究——基于国内六部地方性法规的实证分析

对精神疾病患者实施强制治疗程序包括强制送治程序和强制治疗程序,由于该程序涉及到对人身自由的限制,应该严格遵循法治行政的原则。不过,国内各地所制定的六部精神卫生条例,赋予该程序的法根据并不充足;同时,程序法上的规定也并非十分完善。因此,我国应该尽快制定《精神卫生法》,详细规定强制治疗的程序,为保障精神疾病患者的权益提供坚实的法律根据。     

Assaultive behavior in state psychiatric hospitals: differences between forensic and nonforensic patients

Forensic patients are occupying an increasingly large number of beds in state psychiatric hospitals. The presence of these mentally ill offenders has raised concerns about the risk they present to nonforensic patients. This study compared the rate of assaults and factors associated with assaultive behavior among 308 nonforensic patients and two groups of forensic patients including 469 patients found not guilty by reason of insanity and 76 pretrial patients. Consistent with other studies, nonforensic patients had higher rates of assaults than either group of forensic patients. However, being a forensic patient did not affect the odds of assault when controlling for the effects of demographic and clinical variables in a multivariate logistic regression analysis. Factors associated with assaults in each of the three patient groups were identified using multivariate analyses. Implications are presented for treatment of assaultive behavior, mixing of forensic and nonforensic patients within state hospitals, forensic release policies, and future research.     

No room at the inn: a snapshot of an American emergency room

The emergency rooms of American hospitals have frequently become the principal suppliers of nonurgent primary care to the under- and uninsured. Canvassing published reports and using original data obtained from a representative urban hospital, Erik Olson examines the demographics of the American emergency room and analyzes its finances. The costs of providing primary care are shifted, to the extent possible, to those who can pay. The result is escalating health care costs and a deterioration of quality of care due to overcrowding, leading some hospitals to close their emergency rooms and others to turn away ambulances or "dump" patients who still require critical care. Mr. Olson explains that state antidumping laws and the federal COBRA statute have been ineffective at stemming these practices in the face of severe economic pressure to continue them. Pointing out that emergency rooms are an excessively expensive method of treating uninsured nonemergency patients, he proposes a system of primary care clinics created through a public/private partnership between municipalities and existing private health care providers. The partnership is designed to maintain a high standard of care at the clinics. As an incentive to stimulate the appearance of such clinics, a tax would be imposed on private health care providers; the tax on a given provider would be reduced to the extent that provider subsidizes a local primary care clinic that offers universal coverage, regardless of insurance status. Because the existence of such clinics would reduce inefficient use of hospital emergency rooms, in the long run hospitals should find it less expensive to finance local primary care clinics than to continue to sustain unreimbursed expenses due to improper use of their emergency departments.     

Market Darwinism vs. Market Creationism: Adaptability and Fairness in the Design of Greenhouse Gas Trading Mechanisms

International rule-making and compliance routines with respect to the Kyoto Protocol are evolving rapidly. This paper examines potential designs of emissions-trading programs by comparing the emissions credit trading (ECT) and cap-and-trade models for achieving cost-effective reductions in atmospheric greenhouse-gas (GHG) loading in terms of their adaptability and fairness. Adaptability is a valuable attribute when markets and their governing institutions are evolving rapidly or when regulated entities do not yet have well-established and predictable compliance routines. Fairness in both procedures and outcomes is central to efforts to establish and maintain institutions of international governance. The key difference concerns the awarding of tradable emission rights, which occurs at the launch of a cap-and-trade program but following when firms reduce emissions below baselines in an ECT scheme. Implications of this difference are explored in terms of institutional adaptability and fairness during program-design stages. By not locking in emission rights at the outset, and by being amenable to incremental roll-out, ECT appears to have superior adaptive and fairness qualities during periods of rapid institutional evolution.     

医疗保险干预能否缓解三级医院的“虹吸效应”?——基于某大城市的实证研究

【问题】患者普遍偏好在三级医院就诊,而三级医院对患者的“虹吸效应”直接影响了医疗服务体系的运行效率。差异化报销的医保政策干预成为各地推行“分级诊疗”的普遍手段。虽然三级医院的“虹吸效应”已经得到学界的普遍关注,成为医改领域的热点研究问题,但现有相关研究还主要停留在理论探讨层面。而且,医保政策干预作为分级诊疗推动措施究竟能够发挥多大作用,在实证方面还缺乏足够的文献支持。【方法】文章基于A市的医疗保险数据,使用固定效应等研究方法,对三级医院的“虹吸效应”和医保政策干预效果进行了分析。【发现】三级医院对使用社会医疗保险患者的门诊就医选择有“虹吸效应”,每10万人配备的三级医院数量每增加1家,赴三级医院门诊就医的患者比例就提高5.8%。“虹吸”的主要对象来自二级医院而非一级及以下医疗机构的患者群体。“虹吸效应”存在异质性:无慢性病群体、高收入者、儿童更容易被三级医院“虹吸”。医保政策干预能够缓解“虹吸效应”,且对“小病、常见病”的影响程度更大,可以有效引导把价格敏感的患者向基层医院分流。【贡献】文章从实证上检验了三级医院对需求方的“虹吸效应”及其程度,首次揭示了中国二级医院的“夹心层”困境;通过检验医保政策干预对“虹吸效应”的效果,为医保补偿政策推动分级诊疗提供了新的经验证据。文章对于推动分级诊疗、优化医疗资源配置具有重要的现实意义。     

Outcomes in a low secure unit: pre-admission and post-discharge comparisons

Empirical research seldom reports on clinical outcomes within low secure services. By comparing outcome measures prior to admission and following discharge this study aimed to investigate the care pathways of patients admitted to a low secure unit (LSU). The study was conducted in an LSU and consisted of 70 patients (54 male, 16 female). Data were collected retrospectively and analysed in relation to placement security (upon admission and discharge) and admissions to hospital. Results revealed that admissions to hospital and time spent in hospital decreased post-discharge in comparison with pre-admission. Forensic patients were found to have fewer admissions than civil patients prior to LSU admission. Some differences were also observed within gender and Mental Health Act (MHA) section status for placement security. The findings demonstrated that following treatment in a LSU, care pathways may be less restrictive than prior to admission. Further, more robust research on the outcomes of LSUs is required.     

《精神卫生法》对“被精神病”现象规制之评析

摘要在防止“被精神病”问题上，新出台的《精神卫生法》围绕“送、诊、治”三个环节及再次诊断和鉴定等程序作了较为详尽的规定，但仍存在一些不足。通过对其深入剖析，提出进一步完善强制送治制度、诊断制度、强制住院治疗制度及出院制度的建议。     

Poisoned social climate, collective responsibility, and the abuse at Abu Ghraib--Or, the establishment of "rule that is lack of rule"

The authors draw upon the experiences of one of the co-authors as an expert witness in sociology for mitigation at three of the courts-martial pertaining to the abuse at Abu Ghraib that were held at Ft. Hood, Texas in the year 2005 (for Javal Davis, Sabrina Harman, and Lynndie England). In addition, this paper is based upon the thousands of pages of affidavits, testimony, and U.S. Government reports concerning Abu Ghraib. These internal government reports, as well as the Levin-McCain report, point to collective responsibility and the responsibility of individuals high in the chain of command for establishing unlawful techniques. We review the shortcomings of a purely psychological approach for understanding the abuse, and turn to Durkheim's original understanding of anomie as a state of social derangement or rule by lack of rule to introduce the ideas of the social origins of and social responsibility for the abuse. We conclude with sociological suggestions for reforming some of the legal, medical, psychiatric, and other professional complicity in the abuse at Abu Ghraib.     

修订版外显攻击行为量表用于精神疾病患者危险行为评估

目的 探讨修订版外显攻击行为量表(Modified Overt Aggression Scales,MOAS)对精神疾病患者危险行为评估的价值.方法 采用MOAS对隶属公安、卫生、民政系统的3家精神卫生机构(安康监管病区、华西心理卫生中心、德康救治病区)共490名精神疾病患者根据痛史资料进行评估. 结果 无危险行为31...     

Multiple Imputation of the Supplementary Homicide Reports, 1976–2005

The Supplementary Homicide Reports (SHR), assembled by the Federal Bureau of Investigation (FBI), have for many years represented the most valuable source of information on the patterns and trends in murder and non-negligent manslaughter. Despite their widespread use by researchers and policy makers alike, these data are not completely without their limitations, the most important of which involves missing or incomplete incident reports. In this analysis, we develop methods for addressing missing data in the 1976–2005 SHR cumulative file, related to both non-reports (unit missingness) and incomplete reports (item missingness). For incomplete case data (that is, missing characteristics on victims, offenders or incidents), we implement a multiple imputation (MI) approach based on a log-linear model for incomplete multivariate categorical data. Then, to adjust for unit missingness, we adopt a weighting scheme linked to FBI annual estimates of homicide counts by state and National Center for Health Statistics mortality data on decedent characteristics in coroners’ reports for deaths classified as homicide. The result is a fully-imputed SHR database for 1976–2005. This paper examines the effects of MI and case weighting on victim/offender/incident characteristics, including standard errors of parameter estimates resulting from imputation uncertainty.

Violent behavior in cancer patients--a rarely addressed phenomenon in oncological treatment

Dealing with violent cancer patients can be particularly challenging. The purpose of this study was to collect data on the frequency, quality, and underlying variables affecting violent behavior as well as to examine the role played by this behavior in the premature interruption of treatment. A total of 388 cancer inpatients were examined by liaison psychiatrists. The data were assessed using the Staff Observation Aggression Scale (SOAS-R) and Psycho-Oncological Basic Documentation (PO-BADO); the quality of psychiatric disturbances was measured with a three-level rating according to Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria. Nineteen of 388 patients (4.9%) displayed violent behavior. The variable "cognitive limitations" was clearly associated with aggressive behavior. The interaction factor "constantly bedfast, nonterminal phase, and strong feelings of helplessness or subjection," was associated with aggressive behavior as a trend statistically. Eight of 19 inpatients showing aggressive behavior were prematurely released from the treatment facility. In a multivariate model the association of the variable "aggressive behavior" to premature interruption of treatment with unfinished diagnosis and therapy was weighted rather strong. Despite their methodological limitations, these results suggest that members of oncological teams should be able to identify violent behavior and its precursors at an early stage as important factors, which may decrease patient cooperation.     

Estimating the impact of state manpower policy: a case study of reducing medical school enrollments

Perceptions of an impending oversupply of physicians have prompted proposals to reduce medical school enrollments in a number of states. Most of these states are also concerned with improving the specialty and geographic distribution of their medical manpower. The present study provides estimates of the effects of reduced numbers of in-state medical school graduates upon the future supply of physicians in Texas, and examines the medical school origin, medical specialty, and practice location of selected groups of Texas physicians. The results suggest that in Texas enrollment reductions would have no significant impact on physician supply over the next 15 years, and might actually prove counterproductive in altering physician distribution. The analysis of Texas data illuminates the unintended consequences likely to accompany a policy option that has been widely embraced by state officials largely on the basis of its intuitive appeal.