Biomedical subjects
Publications and source records attributed to J D Bloom.
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A retrospective review of pregnant women admitted to a state psychiatric facility and to an acute university psychiatric unit compares various characteristics of the two populations. No major significant differences were noted in demographic, psychiatric, or obstetric characteristics. It was hypothesized that the patients from the state facility would have a better perinatal outcome secondary to an opportunity for closer prenatal follow-up. No differences were noted in perinatal outcomes between the two facilities. Significantly poorer perinatal outcomes were noted in the combined group of psychiatric patients when compared were noted in the combined group of psychiatric patients when compared with the state of Oregon's birth-outcome statistics. The importance of prenatal care in this high-risk population is discussed, and specific recommendations are offered.
To make quality assurance more outcome oriented, the department of psychiatry in a university hospital developed a program of psychiatric mortality and morbidity conferences for reviewing cases with undesirable outcomes. The conference combines aspects of a traditional medical mortality and morbidity conference with features of utilization review and risk management. Case review is focused on mortality, morbidity, or specific indicators developed by the departmental services involved and on a determination of whether an adverse outcome was avoidable, possibly avoidable, or unavoidable. The authors summarize the 100 cases reviewed in the first seven months. They believe the focus on outcome gives the method a useful role in quality assurance; advantages include its recognizable contributions to continuing education and training.
Many patients, especially those who are elderly and who have chronic medical illnesses, choose to forgo cardiopulmonary resuscitation (CPR) in case of cardiac arrest. The right of mentally competent patients to refuse CPR is supported by ethicists, the courts, and medical associations. Psychiatrists are increasingly presented with dilemmas about resuscitation preferences of elderly psychiatric inpatients whose decision-making capacity may be impaired because of mental illness such as depression. The authors discuss justifications for patients' refusing resuscitation, the role of advance directives in communicating patients' preferences, and the use of do-not-resuscitate orders for depressed psychiatric inpatients. Survival rates after CPR among elderly patients with chronic medical illnesses are low. Patients and their families need accurate information about the risks and benefits of CPR and about the consequences of refusing the procedure.
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This article described the mental health and criminal justice involvement of a large group of schizophrenic insanity acquittees and the program designed to manage and treat these individuals. Most insanity acquittees in our system are chronically mentally ill individuals who fit well into the psychosocial rehabilitation models that have developed over the past 15 years. In addition, the use of conditional release and monitored care in the community appears to be the most realistic approach to this group of individuals who show a high degree of involvement with the mental health and criminal justice service systems. This research has continued implications for the development of outpatient civil commitment and for the attempt to give people as much liberty as they are capable of handling while being realistic about their capacities to survive in the community.
STUDY OBJECTIVE: Violence in the emergency department, a not uncommon but complex phenomenon, may become more serious when patients possess weapons. Searches are used frequently to reduce this danger, though guidelines for searches are not well delineated. We examined our practices in order to formalize our guidelines. DESIGN: Retrospective chart review of patients found to be carrying weapons. SETTING: General, university-based emergency department in the Northwest. PARTICIPANTS: Of 39,000 patients seen during the 20-month study period, 500 (1.3%) were searched. MEASURES AND MAIN RESULTS: Of all patients seen in the ED, 92% were medical patients (153, 0.4% of whom were searched) and 8% were psychiatric patients (347, 11.1% of whom were searched). Weapons were found on 89 patients (0.2% of all ED patients and 17.8% of all patients searched). Review showed that 24 (15.7%) medical and 60 (17.3%) psychiatric patients carried weapons. CONCLUSION: Although various factors contributed to a clear bias toward searching psychiatric patients, we believe that the rate of weapons possession did not support this bias.
This article describes the evolution of psychiatric consultation to the Oregon Board of Medical Examiners. The board is charged with the licensing and regulation of physicians in the state of Oregon in order to protect the public and uphold the standards of the medical profession. Psychiatric consultation has focused on the board's investigations of physicians with mental illness and/or substance abuse and physicians who inappropriately prescribe psychoactive drugs or sexually abuse patients. Each of these physician groups is described, and remedial programs for each group are discussed. The authors conclude that psychiatric consultation to medical boards is a feasible and productive activity that can make a positive contribution to the lives of a large number of physicians and patients.
This article reviews the recent literature documenting changes that have taken place in the management and treatment of insanity defense acquittees with the development of conditional release and monitored community treatment. The review demonstrates that conditional release is particularly important as a means of balancing the protection of society with the treatment of insanity defense acquittees in the least restrictive environment. The review also highlights the development of community programs based on treatment models for the chronically mentally ill. In addition, monitored community treatment programs appear cost-effective when compared with hospital-based programs. These factors point to the development in the 1990s of program standards for the release of insanity defense acquittees.
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The authors describe a group of pregnant psychiatric patients admitted to a psychiatric service in an urban hospital. A high rate of involuntary admission (44%), homelessness (36%), and substance abuse (64%) was noted. In this group of high-risk obstetric patients, we identified risk factors associated with noncompliance with ongoing prenatal care. Brief psychiatric hospitalization can be an important aspect in improving obstetric outcome by providing an opportunity to collect obstetric information and promote ongoing prenatal care.
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As part of a survey of 260 Oregon family members with mentally ill relatives, respondents were asked about their experiences with civil commitment and their opinions about proposed modifications in the commitment statutes. Family members typically described their mentally ill relative as a schizophrenic man in his thirties who had had six psychiatric hospitalizations and was currently being treated with medications at a community mental health center. Three-fourths of the relatives had been committed. A majority (57 percent) of the respondents were in favor of mandatory outpatient treatment and medication after involuntary hospitalization but were not enthusiastic about outpatient commitment without hospitalization. Family members also wanted more education about mental illness, more information about the commitment process, and assignment of a professional to help in the commitment process.
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The 1983 Oregon legislature responded to public pressure to narrow the application of the insanity defense by eliminating personality disordered individuals from consideration for an insanity verdict. This article examined the effects of the statutory change, and found no significant change in the frequency of insanity acquittals of personality disordered subjects between the three pre-reform years (n = 21) and the three post-reform years (n = 14). We also reviewed how the Psychiatric Security Review Board handled these patients once committed to their jurisdiction. We constructed a matched comparison group of psychotic acquittees and found that in the pre-reform years the personality disordered subjects spent less time in the system and less time in the hospital than the psychotic patients. However, in the post-reform years their time in the system and time in the hospital was the same as the psychotic controls. There were fewer decisions to discharge personality disordered patients from the system after the reform, although this difference may be due to factors other than the statutory reform itself. The conclusion is that narrowing the insanity defense is a worthy goal which may be difficult to achieve.
In this article, the authors review the literature on surveys pertaining to threats and assaults on psychiatrists and report the results of a questionnaire sent to Oregon psychiatrists. Although the responding psychiatrists were experienced clinicians, they appear to have had relatively little life experience with aggression. Assaults and threats were frequent in their careers, occurred across a variety of clinical settings, and involved a wide range of patients. The authors discuss specific strategies for psychiatrists to minimize the effects of patient threats and assaults and suggest ways in which organized psychiatry can help with the danger and sequelae of patient violence.
Research on the management and treatment of insanity acquittees and the right to refuse treatment illustrates the need for empirical analysis in the overlapping areas of law, mental health services, and public policy issues.