"Theory of Mind" and Executive Functioning in Forensic Patients with Schizophrenia

Abstract:  Previous studies in forensic patients with schizophrenia have shown that delinquent patients may outperform nondelinquent patients with regards to "theory of mind" (ToM). Findings were, however, confounded by a lack of control for executive functioning. We examined 33 forensic patients with schizophrenia regarding ToM, intelligence, executive functioning, and psychopathology. Results were compared with a nonforensic schizophrenia sample and a group of healthy controls. Both patient groups performed more poorly on most measures compared with controls. Forensic and nonforensic patients did not differ in task performance. In the forensic group ToM correlated inversely with "excitement" and cognitive symptoms. When "excitement" was covaried out, forensic patients outperformed nonforensic patients with regards to ToM. This study supports the hypothesis that schizophrenic patients with a criminal record are equally impaired in their ability to infer mental states compared with nonforensic patients, but for different reasons associated with a divergent psychopathological profile.     

Invocation of coercion context in compliance communication -- power dynamics in psychiatric care

This article draws on observations from ethnographic fieldwork to develop a theoretical understanding of the power dynamics in psychiatric care. The aim is to analyze how psychiatric clinicians solve compliance problems by invoking "coercion context". It is suggested that clinicians take a rather instrumental approach to laws regulating coercive intervention. Clinicians may invoke a coercion context even with voluntary patients. For example, they may use wordings that connote coercion, or they may make use of how treatment wards are set up to accommodate involuntary patients, thus stalling voluntary patients who cannot exit through locked doors. A coercion context can also be invoked to solve mundane practical problems, e.g. when clinicians talk about "coerced showers". The management of information and maintaining a suitable "awareness context" with regards to coercion is an essential feature in clinical attempts to achieve compliance from patients. In conclusion, the notion of coercion context helps explain the confusing findings from previous research about patients' apparent misconceptions of their formal legal status. Furthermore, it is argued that research that rely on decontextualised, objectifications of "coercion" risk to miss the meaning coercion is assigned in everyday clinical practice.     

The papal allocution on caring for persons in a "vegetative state"

On March 20, 2004, Pope John Paul II issued a statement to the International Conference on "Life Sustaining Treatments and Vegetative State: Scientific and Ethical Dilemmas" on the provision of food and water to patients in a "vegetative state." The purpose of this allocution was to promote and protect the dignity of patients, even when they are in a seriously ill and disabled state. To promote the dignity of these patients, the Pope explicitly stated that "quality of life judgments" were not to be applied to the administration of nutrition and fluids. The Holy Father made it clear that he was avoiding any position that could be construed as tolerating, permitting, or promoting euthanasia by omission. His statement sought to prevent Catholics and Catholic health care facilities from becoming involved in euthanasia by omission that has become a fast-growing threat.     

A critique on the concept of "brain death"

Since the concept of "brain death" was introduced in medical terminology, enough evidence has come to light to show that the concept is based on an unclear and incoherent theory. The "brain death" concept suffers by internal inconsistencies in both the tests-criterion and the criterion-definition relationships. It is also evident that there are residual vegetative functions in "brain dead" patients. Since the content of consciousness is inaccessible in these patients who are in a profound coma, the diagnosis of "brain death" is based on an unproved hypothesis. A critical evaluation of the role and the limitations of the confirmatory tests in the diagnosis of "brain death" is attempted. Finally it is pointed out that a holistic approach to the problem of "brain death" in humans should necessarily include the inspection of the content of consciousness.     

Psychopathy,Treatment Involvement,and Subsequent Violence Among Civil Psychiatric Patients

Individuals with psychopathy typically are viewed as incurable cases that should be diverted from treatment settings to environments where their behavior can be monitored and controlled. The prevailing clinical conviction that psychopaths are untreatable has crucial implications, given the scarcity of mental health care resources, the number of legal contexts that call for assessment of treatability, and the explosion of research on psychopathy and violence risk over recent years. Based on a sample of 871 civil psychiatric patients (including 195 potentially psychopathic and 72 psychopathic patients), this study explores the relations among psychopathy, receipt of outpatient mental health services in real-world settings, and subsequent violence in the community. The results suggest that psychopathic traits do not moderate the effect of treatment involvement on violence, even after controlling statistically for the treatment assignment process. Psychopathic patients appear as likely as nonpsychopathic patients to benefit from adequate doses of treatment, in terms of violence reduction. We interpret these results in light of prior research with offenders and analyze their implications for future research, policy, and practice.     

Gender and Risk Assessment Accuracy: Underestimating Women’s Violence Potential

Understanding factors that contribute to mental health professionals (MHPs) accuracy in assessing patients risk of violence can inform efforts to improve accuracy and to integrate risk assessment technology with practice. Based on a sample of 147 clinicians who assessed 680 patients in a psychiatric emergency room, this study investigates the influence of patient gender, MHP gender, and their potential interaction on MHPS risk assessment accuracy. The results indicate that MHPs of both genders are particularly limited in their ability to assess female patients risk of future violence. This finding was not limited to a particular professional group and was not attributable to gender-related differences in violence. Implications for future research on the judgment processes that may underlie MHPs limited accuracy with women and for training programs in violence risk assessment are discussed.     

Hospital care for the "self-pay" patient

The number of hospitalized patients lacking an identifiable source of third-party payment has risen substantially in recent years. This study examines trends in the hospitalization of "self-pay" patients and investigates causal influences on the propensity of hospitals to accept such patients for treatment. Our analysis pays particular attention to the relationship between Medicare's prospective payment system (PPS) and hospitals' self-pay patient share. Our results show an overall increase in both the number and proportion of self-pay patients treated by hospitals between 1980 and 1985. Substantial differences existed among the types of hospitals that accepted such patients, with major teaching hospitals treating an increasingly disproportionate share. The mix of self-pay patients in terms of age, sex, and reason for hospitalization remained stable during the period under study. Our conclusion is that the regression analysis shows no evidence that PPS reduced hospitals' willingness to treat uninsured patients.     

服刑能力司法精神鉴定研究

为探索服刑能力鉴定的相关因素 ,对102例服刑能力评定的案例进行分析研究 ,以自制的“服刑环境适应调查表”进行调查比较。结果发现精神病性障碍及以往有精神异常史者无服刑能力比率较高 ,且服刑环境适应能力差     

Per case prospective payment for psychiatric inpatients: an assessment and alternatives

Psychiatric hospitals and clinics are exempted from the Medicare prospective payment system. In this paper we examine the appropriateness of the DRG classification system for psychiatric patients and argue that, using this system as the basis of payment, two types of problems are likely to arise. We categorize these problems as "risks to hospitals" and "risks to patients" and examine the existing literature to determine whether these risks are likely to be significant. We propose a different approach to paying prospectively for psychiatric care, and suggest modifications that could be made to the structure of PPS to mitigate negative incentives embedded in the current system. Although the main focus of the paper is on the unit of payment, we also make some observations about issues arising in connection with the level of payment.     

End-of-life decision-making, the principle of double effect, and the devil's choice: a response to Roger Magnusson

Recently, the principle of double effect has come under scrutiny by Magnusson who believes it provides a subterfuge for those who act so as to end the lives of their patients. Specifically, he argues that the conceptual distinction between foresight and intention is dubious and, moreover, renders patients vulnerable to involuntary euthanasia. At the same time, Magnusson wants to protect doctors from criminal liability when faced with (what he understands to be) a "devil's choice" between ending the life of a patient or under-treating pain. Hence, Magnusson proposes that, subject to specific conditions, a so-called "defence of necessity" be recognised through either common law doctrine or legislation. However, to safeguard this defence, he must rely on what he most wants to reject: a fundamental aspect of the principle of double effect.     

Teaching "street law" to the criminally insane

A course in "Street Law" was taught to forensic patients by law students, following a format used by Georgetown University Law Center. Although the course has been taught to high school students and inmates of correctional facilities, this was the first time it has been extended to mental patients found not guilty of crimes by reason of insanity. An outstanding feature of the course was marked enthusiasm shown by patients who, through long institutionalization, had become apathetic, indifferent, and despairing. Their readiness and ability to learn brought to mind a couple of old sayings often heard around mental hospitals, "I may be crazy but I'm not stupid," and "Sometimes you can't tell the patients from the staff." The staff of at least one ward has picked up "teaching and learning to use as a central theme in treatment of patients, not abandoning traditional methods, but shifting the emphasis from therapy to teaching as a way of getting the patient's interest in his own rehabilitation. Judges, reviewing cases for release, have looked quizzical when the patients' active participation in a "law course" has been used as evidence of satisfactory progress.     

Medicare program; coverage of erythropoietin (EPO) used by competent home dialysis patients--HCFA. Interim final rule with comment period

This final rule-- Provides for Medicare coverage of EPO used by ESRD beneficiaries who dialyze at home and are competent to use the drug without medical or other supervision; and Establishes criteria for selection of patients that can be considered "competent" and for monitoring of the patients who are selected. This rule is necessary to implement section 4201(d)(1) of the Omnibus Budget Reconciliation Act of 1990 (OBRA '90). The purpose is to facilitate use of EPO at home, while ensuring that such use of the drug is safe and effective.     

Involuntary outpatient commitment.

This article offers a novel approach to outpatient commitment (OPC). After distinguishing 4 varieties of OPC, the article shows how 3 are easy to justify, whereas "preventive outpatient commitment" (POC) requires more careful scrutiny. The article argues that, as a general matter, POC is not justified, except for on a "one free shot" basis. The hope is that patients will come to appreciate the benefits of treatment in the community and will become voluntarily compliant; after one free shot, they are in a much better position to decide. The consequences of noncompliance are also explored.     

Right to refuse treatment: impact of Rivers v. Katz

This article examines the impact of the New York court decision, Rivers v. Katz, which in June 1986 dramatically changed the state procedure for responding to involuntarily committed psychiatric patients who formally refused psychopharmacologic treatment. The court rejected the medically administered review process that had been used to respond to involuntarily committed psychiatric patients who formally refused medication, and replaced it with a judicial determination of competent and "substituted judgment" provided by the court. Post-Rivers, the rate of patients consistently refusing treatment decreased, and the time from refusal to resolution increased. The clinical, legal, and economic implications of the Rivers procedure are discussed.     

How do uncompensated care pools affect the level and type of care? Results from New York State

Uncompensated care pools have been used by several states in their attempt to aid hospitals and increase the volume of care provided to patients without health insurance. We examined the uncompensated care pool used in New York State between 1983 and 1987. Our primary interest was to estimate the impact of the pools on the level and type of care provided to uninsured patients. Our results indicate that hospitals responded to the pools by increasing the volume of care provided to uninsured patients. Without the pools, over 30,000 fewer adjusted hospital admissions would have been provided to the uninsured in a typical year. Many of these newly purchased admissions were for "nondiscretionary" medical care, suggesting that beneficial care to the indigent was rationed prior to the introduction of the uncompensated care pools.     

The impact of a change in commitment procedures on the character of involuntary psychiatric patients

The statutory requirements for involuntary civil psychiatric confinement have become increasingly restrictive. In the jurisdiction under investigation, patients were originally admitted under an Order to Apprehend (OTA) procedure simply on the petition of two affiants who indicated the patient was in need of care. A newly elected judge instituted changes requiring affiants to claim the subject was "dangerous" to self or others and asking for a clinical assessment and recommendation before signing the petitioned request for involuntary confinement. It might be expected that the more restrictive procedures would have produced a population of more assaultive patients. A study of petitions signed under in the earlier (N = 133) and later, more restrictive (N = 218) procedures indicated that the proportion of assaultive or dangerous patients was virtually identical. Further investigation, using hospital data an OTA patients from this area in both time periods, suggested that while patients were not more assaultive, they appeared to be more seriously ill or psychiatrically impaired. Apparently, movement to a dangerousness standard that allows clinical discretion in interpreting its presence may result in involuntary commitments for more seriously ill, although not necessarily more assaultive, patients.     

The patient who refuses medical treatment: a dilemma for hospitals and physicians

This article reviews recent case and statutory law concerning patients who refuse medical treatment. Among the special cases considered are: the competent adult patient who refuses treatment on religious or privacy grounds; the incompetent patient whose own wishes were never expressed, but whose family refuses treatment; the incompetent patient who expressed the wish not to be treated before becoming incompetent; and parents who refuse treatment on behalf of their child. It is pointed out that recent court decisions have blurred the distinctions between "extraordinary" care and "ordinary" care and between withholding and withdrawing life-sustaining treatment. Reference is made to the recent trend toward allowing the family of an incompetent patient to assert the patient's rights without court intervention either in the form of direct court order or through guardianship proceedings. Finally, the implications of these legal developments for health care institutions are discussed. A protocol pertaining to incompetent patients is proposed. Health care institutions are encouraged to develop formal policies for dealing with patients who refuse treatment, and to work with their professional associations in lobbying for legislation which will clarify the law in this area.     

Disease management: legal strategies for the next generation of managed care

The provision of proper and cost-effective healthcare to chronically ill patients is a crucial aspect of succeeding at managing care. An increasing number of managed care organizations are relying upon specialized outside providers to manage patients with such diseases. In such circumstances, this type of care is "carved out" and given to a specialized disease management organization. The authors discuss the strategies behind such arrangements, provide case studies of many of the specialized organizations providing such disease management, and analyze the legal issues that are likely to arise from such contractual relationships.     

Special report on reimbursement. The safe harbor for small investment interests: where do joint ventures go from here?

There is no specific federal self-referral legislation presently proposed or in effect that statutorily prohibits providers from referring Medicare or other patients to entities in which the referrers have an investment interest, except for existing "Stark" legislation, which applies only to clinical laboratory services, effective January 1, 1992. (See Newsletter, Vol. 6, No. 1, January 1991, at 3.) Thus, health care joint ventures are not per se illegal. The publication of the Safe Harbor Regulations does nothing to change this fundamental fact, and it should not cause providers to abandon existing joint ventures, or planned ones, in a "knee-jerk" fashion, without careful analysis. Of course, there is no guarantee that expanded "Stark" legislation, or some other new self-referral legislation, will not be enacted in the future to prohibit providers from referring patients to entities in which they have an investment interest. Because of this uncertainty, all health care joint ventures should contain "unwinding" provisions to govern the rights and obligations of investors in the event that the venture is required to, or the participants voluntarily elect to, dissolve. Any new venture being contemplated should plan for dissolution, and existing ventures should undertake an internal review of their charter documents to assess whether the rights and duties of all participants upon dissolution are properly spelled out. If not, amendments should be made now, while all participants are on good terms. A failure to agree in advance upon such important issues is an invitation to discord, and possibly even litigation.     

Involuntary outpatient treatment in patients with severe mental illness: A one-year follow-up study

Introduction

Involuntary outpatient treatment (IOT) aims to ensure adherence to therapy in patients with serious mental disease who are unaware of their illness and for whom treatment discontinuation carries a high risk of relapse.

Objectives

To evaluate the effectiveness of IOT in preventing relapse among patients with serious mental disease.

Method

A retrospective observational study was carried out on all of the patients (n = 140) receiving IOT in the city of Valencia, Spain. Hospital service uses (emergency care, admissions and mean stay times) during the 12 months before and after the introduction of IOT were compared.

Results

Patients with schizophrenia, delusional disorder or schizoaffective disorder showed a significant reduction in the number of admissions and days spent in the psychiatry ward during the year of IOT. The reduction in the number of visits to the emergency department was only significant for the patients with schizophrenia.

Discussion

We conclude that involuntary outpatient treatment may be effective for patients with serious mental disease who are unaware of their illness and for whom treatment discontinuation carries a high risk of relapse.