Psychiatric Division Research Articles

Divergencies between a medical and a psychiatric hospitalization: Admissions, aggressiveness, and characterological suicidality in severe personality disorders

ContextThere have been significant advances in organizational and administrative practices of modern psychiatric institutions. These advances have allowed their capitalization in the therapeutic use of social sub-systems and the interaction between staff and patients, in inpatient hospital programs. The therapeutic use of the interaction between patients and personnel is the essence of contemporary psychiatric divisions: this is what truly distinguishes modern psychiatric services from traditional medical models. However, the enormous gap between these advances and their more universal applications to the contemporary psychiatric hospital is disconcerting. Objectives(a) To raise awareness of the differences between a medical and a psychiatric inpatient program; (b) so as to truly appreciate the importance of the therapeutic use of the interaction between personnel and patients; (c) particularly in the context of treating aggressiveness and characterological suicidality in severe personality disorders. MethodIn this study the divergencies between a medical and a psychiatric hospitalization are critically explored along four dimensions: (1) body versus mind; (2) reasons for admissions; (3) pharmacological approaches; and (4) characterological suicidality and aggressiveness in severe personality disorders. ResultsLamentably, the non-delimited and confusing transposition of traditional and psychiatric models, in inpatient psychiatric programs which do not integrate a comprehensive supraordinate psychotherapeutic framework at the service of their primary tasks, results in the risk of highly restrictive and merely custodial care of patients; unintegrated salads of multiple psychotherapeutic modalities, without a holistic approximation to articulate them; and the mixture of interventions that cancel each other out and could even result iatrogenic for patients and staff. It is precisely in the dimensions of characterological suicidality and aggressiveness, that the overall containment and treatment of suicidal behavior and the rampant infiltration of aggression in severe personality pathology call for a clear demarcation between a medical model and a genuinely psychiatric one. InterpretationsContrary to the erroneous prediction of a few decades ago, about the disappearance of the psychiatric hospital, the need of modern psychiatric institutions and psychiatry programs that integrate the achievements and contemporary proposals in mental health and psychotherapeutic sciences is more imperative than ever. This situation will demand an ongoing effort to explore critically our psychiatric practices and to address the enormous challenges represented by the training of staff, professors, and residents in psychiatry, toward the optimal use and advancement of available hospital resources.

The Establishment of a Clinic for Personality Modulation in Iran: A Novel Approach in Personality Psychiatry with a Dimensional Approach

The Establishment of a Clinic for Personality Modulation in Iran: A Novel Approach in Personality Psychiatry with a Dimensional Approach

Juvenile Crime and Dissent in Nazi Vienna, 1938–1945 by Evan Burr Bukey

Reviewed by: Juvenile Crime and Dissent in Nazi Vienna, 1938–1945 by Evan Burr Bukey Joshua Parker Evan Burr Bukey, Juvenile Crime and Dissent in Nazi Vienna, 1938–1945. London: Bloomsbury Academic, 2020. 197 pp. Second World War resistance continues to have an important relevance to Austrian national identity. The main points raised by the research in Evan Burr Bukey's Juvenile Crime and Dissent in Nazi Vienna, 1938–1945 relate to two questions. Youth resistance movements in occupied countries like France and Denmark, and in cities like Hamburg and Munich, are well documented—but what of youth resistance in the "Ostmark"? And what do we mean, as Karl Stadler once asked, by "resistance," by "dissent," and by criminalized acts prosecuted by a government that is itself criminal? Bukey's research is based on records from the Viennese Municipal and Provincial Archives and the Documentation Centre of Austrian Resistance. Only partial records exist—many were accidentally discarded in 1999. Bukey surveys the remaining 437 judicial records, the largest group of which are from 1945. Individual cases offer glimpses of the family backgrounds of those charged. After 1938, treason cases were tried by laws based on Prussian jurisprudence in People's Courts, whose judges often abused and humiliated those found guilty. Aside from treason, Austrian criminal code largely preserved continuity before and after 1938, though now interpreted through "völkisch norms" (11). Bukey suggests that Hitler's regime controlled youth crime more effectively in Vienna than in other large cities of the Reich (162). During the first few months after the Anschluss, youths convicted of break-ins and petty theft were often sent to youth detention centers for [End Page 164] several months. More serious theft was punished with hard labor. Moral offenses, particularly homosexuality for those over sixteen years of age, were punished more harshly. But the most severe punishments were reserved for political acts of defiance. A turning point came with the introduction of the Reich Juvenile Court Act in 1944, which sought to pass judgments based on character. Children diagnosed as "precocious juvenile criminals" were sent to the psychiatric division of a correctional facility; youth deemed capable of reform were treated more lightly (122). Homosexuality, with arrests rising sharply from 1938 to 1945, was punished under the Austrian penal code, while illicit intercourse with foreigners was punished under Nazi racial ordinances. In Vienna, 75 percent of juvenile convictions involved property crimes, and absent fathers were seen as a major cause of youth delinquency. Much of the volume's interest lies in its vignettes of everything from angry public verbal outbursts to sabotage, including a sixteen-year-old arrested for stealing switches from Viennese streetcars in 1945 (152). An eleven-year-old was discovered scribbling "Hail Moscow" on scraps of paper in a toy store, which led to the arrest of twenty children involved in a resistance ring (35). A seventeen-year-old mechanic was sentenced to three months of confinement for questioning the war effort, refusing to listen to Hitler's speeches, and proclaiming that Hitler could "kiss his ass" (88). Five youths were arrested by the Gestapo for loudly applauding at a choir performance by Russian émigrés. Several teenagers were imprisoned for joining the Austrian Freedom Movement. Others typed and distributed flysheets based on British news reports and were beaten and sent to Berlin to stand trial for high treason, sentenced either to death or to half a dozen years of prison. Former staunch Social Democrats had often become radicalized Communists under Schuschnigg's regime, a transition that increased following the invasion of the Soviet Union. Of some two thousand Communists arrested by the Vienna Gestapo, at least thirty were minors (107), who were more severely punished than other resistors. After 1943, crackdowns were made on partial Jews, often for absenteeism, labor indiscipline, attempting to flee abroad or escape deportation, or spreading "false rumors" (109). Offenses committed by Viennese adolescents "mutated as the war drew to its conclusion" (126), with the increasing theft of goods that could be sold on the black market or food and increasing refusals to work or instances of tardiness. During the war, juveniles convicted of subversive activities (whether listening to foreign...

Risk-mitigation measures in a tertiary care psychiatric hospital during COVID-19 pandemic

Risk-mitigation measures in a tertiary care psychiatric hospital during COVID-19 pandemic

M170. GENETIC CHARACTERIZATION OF A COHORT OF PATIENTS AFFECTED BY SCHIZOPHRENIA. THE ROLE FOR RARE STRUCTURAL VARIANTS IN MODULATING TREATMENT RESISTANT ENDOPHENOTYPES: PRELIMINARY DATA

BackgroundSchizophrenia (SCZ) is a debilitating mental illness characterized by a highly complex, heterogeneous, non-mendelian genetic background. Recent progress in dissecting genetic architecture of SCZ has accelerated over the last decade due to new advanced technologies. Genome-Wide Association Studies (GWAS) on extremely large samples of patients identified and replicated hundreds of Single-Nucleotide Polymorphism (SNPs), each exhibiting only a modest effect. The analysis of genomic Copy Number Variations (CNVs) clarified the role of rare structural variants conferring significant risk by disrupting multiple genes involved in neurodevelopmental pathways, and linked to SCZ. In this scenario, the aim of our study is to carry out a genetic characterization of a cohort of patients affected by SCZ, in order to assess the risk of recurrence, to elucidate putative pathogenetic mechanisms and, whenever possible, to conceive tailored interventions and therapies.Methods34 patients (8 women and 26 men) affected by SCZ and admitted to Day Hospital at Psychiatric Division for Treatment Resistant Psychosis of the University of Naples Federico II were recruited, and underwent: i) psychopathological evaluation and assessment of clinical response to antipsychotics; ii) genetic counseling; iii) further diagnostic investigation by using Comparative Genomic Hybridization (CGH) + Single Nucleotide Polymorphism (SNP) microarray with 2x400k Agilent’s platform “GenetiSure” for detecting unbalanced chromosomal abnormalities and regions of homozygosity (ROHs).ResultsStructural pathogenetic rearrangements resulted in 9 (27%) patients. Those identified were the following: 15q13.3 deletion, 16p13.11 duplication, 22q11.22 deletion (TOP3B), 22q11.22 (PRODH, DGCR5, DGCR6), RBFOX1 deletion, TCF4 deletion, derivative X chromosome (X;Y translocation).Potentially pathogenic rearrangements, involving genes associated with psychiatric disorders or implicated in neurodevelopment, resulted in 15 patients (44%).No relevant CNVs were detected in 10 patients (29%), although they showed the presence of ROHs that may contain susceptibility loci, since many neurodevelopmental genes map onto or near these specific regions.Certain of these rearrangements occur in many patients, and certain patients showed likewise multiple rearrangements.DiscussionThe analysis of CNVs and SNPs allowed us to characterize the genetic disease structure in the whole cohort of patients and helped to refine the diagnosis in a few cases, thereby ascertaining an underlying specific genetic condition. A further extension of the study, in terms of sample size and more accurate investigations (i.e genetic mapping of ROHs) is underway. According to literature, rare risk-associated CNVs account for 2% of SCZ cases, but their higher prevalence (27%) in our sample may be influenced by a larger percentage of Treatment Resistant and more severely ill patients (since they were recruited in a highly specialized Unit for Treatment Resistant Psychosis). Therefore, our future purpose is to demonstrate a robust genetic modulation of Treatment Resistant endophenotypes of SCZ.Moreover, we believe that the role of genetic counseling in psychiatric services should be emphasized, and that genetic testing in this field should not be restricted to suspected childhood neuropsychiatric disorders. According to the neurodevelopmental hypothesis of SCZ, that suggests a brain development disruption in early life (due to genetic and early environmental factors), prompting to a subsequent later emergence of the disease in adulthood, even chronic complex adult mental illness, such as SCZ, deserves detailed investigations and a more exhaustive genetic evaluation.

La liberté de choix des personnes faisant l’objet de soins psychiatriques

We cannot separate a relationship's care based on trust from the raising of patient's ability to freely express his decisions, the core capability of health relationships. If the goals in access of care and patient's rights protection are clearly laid down, the issue about the freedom of choice of the mentally ill person is still subject to caution, particularly in the context of the psychiatric division into sectors. The French legislative texts do not specify a clear boundary about the inability to consent to the care and it is up to the doctor to approve of its validity. The consent, valued by modern sanitary democracy, is disputed by the need for mental security but is consolidated by the search for a therapeutic alliance. The permanence of a conflicting situation explains the confrontation between a defense of the human Rights, hic and nunc, and a free choice assertion by the society.

Association of Child and Adolescent Psychiatric Nurses Division Update

Association of Child and Adolescent Psychiatric Nurses Division Update

Factors relating to effectiveness data use in healthcare management

PurposeThe aim of this study is to produce information concerning factors which may hamper or promote the use of effectiveness data in secondary health care middle and upper management. Additionally, the study aims to acquire knowledge of the ways in which the managers would generate effectiveness data for use in their own work.Design/methodology/approachThe study was conducted by interviewing department directors, chief medical officers and directors of nursing (n=38) in the surgical, medical and psychiatric divisions of the five largest hospital districts in Finland.FindingsThe use of effectiveness data in management was hampered by factors relating to research, managerial work and the organization. Factors relating to the production of effectiveness data, managerial behaviour and a universal demand for evidence‐based operations were considered conducive to the use of such information. Managers would cultivate the use of effectiveness data by improving its accessibility, usability and visibility.Practical implicationsThe findings may help healthcare organizations in developing the use of effectiveness data in their decision‐making.Originality/valueThe paper addresses managers’ willingness to apply effectiveness data in decision‐making although the present quality, reliability and accessibility of effectiveness data do not meet the managers’ needs. The use of effectiveness data in management can be influenced by enhancing organizational patterns of action and supporting managerial decision‐making.

Psychotropic drug-induced weight gain and other metabolic complications in a Swiss psychiatric population

PurposeTo describe the weight gain-related side-effects of psychotropic drugs and their consequences on metabolic complications (hypercholesterolemia, obesity) in a Swiss cohort of psychiatric patients. MethodThis cross-sectional observational study was performed in an out-patient psychiatric division with patients having received for more than 3 months the following drugs: clozapine, olanzapine, quetiapine, risperidone, lithium, and/or valproate. Clinical measures and lifestyle information (smoking behaviour, physical activity) were recorded. Results196 inclusions were completed. Weight gain (≥10% of initial weight) following drug treatment was reported in 47% of these patients. Prevalence of obesity (BMI ≥ 30), hypercholesterolemia (≥6.2 mmol/L) and low HDL-cholesterol (<1.0 mmol/L in men, <1.3 mmol/L in women) were present in 38%, 21%, and 27% of patients, respectively. A higher standardised dose, an increase of appetite following medication introduction, the type of medication (clozapine or olanzapine > quetiapine or risperidone > lithium or valproate), and the gender were shown to be significantly associated with evolution of BMI. ConclusionHigh prevalence of obesity and hypercholesterolemia was found in an out-patient psychiatric population and confirms drug-induced weight gain complications during long-term treatment. The results support the recently published recommendations of monitoring of metabolic side-effects during treatment with atypical antipsychotics. Moreover, the weight gain predictors found in the present study could help to highlight patients with special health care management requirement.

The Trend of the Use of Neuropsychological Tests in the Korean Psychiatric Division for the Past 10 Years : Focused on Dementia Research

우리나라는 전세계적으로도 유례없는 노인 인구의 급격한 증 가로 인하여 지난 2000년 노인 인구 비율이 전체 인구의 7.2%로 이미 고령화사회에 진입하였다. 2018년에는 그 비율이 14.3% 로 고령사회에, 2026년에는 20.8%에 달하여 초고령사회에 진입할 것으로 전망된다. 노인 인구 증가와 더불어 대표적인 노인성 질환인 치매의 유병률이 급속하게 증가하고 있는데, 2008년 전국치매역학 조사 결과 우리나라 65세 이상 노인에 서 치매 유병률이 8.1%로 나타났으며, 2030년에는 9.9%에 도 달할 것으로 추정된다. 치매는 환자와 환자 가족 및 사회적으로도 막대한 부담을 초래하며 특히 중증으로 진행할수록 그 비용이 크게 증가한 다. 개인의 삶의 질을 제고하고 사회적 비용을 감소시키기 위 한 목적으로 치매의 조기 진단과 치료에 대한 중요성이 증가 하고 있다. 최근에는 뇌영상의 발달로 치매의 전임상단계(preclinical stage)나 전구단계(prodromal stage)에서 향후 치매 단계로의 진행을 조기에 예측하기 위하여 기저 병태생리의 진행을 확인할 수 있는 생물학적 표지자(biomarker)을 이용 하려는 노력이 증가하고 있다. 여기에는 뇌자기공명영상, 양 전자방출단층촬영, 뇌척수액검사 등 생물학적 표지자와 유 전적 위험인자가 포함된다. 그러나 임상 실제에서 치매 진단 보다는 전임상단계에서 병리적 변화를 확인하는데 보다 초 점이 주어져 있다는 점과 검사 비용 및 보험적용 여부 등 의 료환경 문제 등으로 인해 생물학적 표지자 검사들의 사용은 아직 제한적이다. 이러한 가운데 천장 효과나 수행의 신뢰도 국내 정신과 영역에서 최근 10년간 신경심리검사 사용의 추세 : 치매 연구를 중심으로

Knowledge of effectiveness and its application in secondary healthcare management

PurposeThe purpose of this paper is to map out managers' understanding of effectiveness and to assess the application of knowledge of effectiveness in secondary healthcare management. Additionally, the study aims to assess the present situation of effectiveness research and the measures used in divisions of treatment.Design/methodology/approachThe study was conducted by interviewing department directors, chief medical officers and directors of nursing (n=38) in the surgical, medical and psychiatric divisions of the five largest hospital districts in Finland.FindingsThe concept of effectiveness was complex, and difficult to concretise and understand uniformly. Knowledge of effectiveness supports both clinical and administrative management. Managers have different ways of applying knowledge of effectiveness depending on their managerial role. Effectiveness studies and measurement are still relatively rare in secondary healthcare and rarely identified as such by management.Practical implicationsThe concept of effectiveness is not clear in management. Managers have an unclear understanding of knowledge of effectiveness and its application in secondary healthcare management.Originality/valueThe paper addresses the need for a discussion on effectiveness in secondary health care. In addition, managers need knowledge and support for implementing the policy of effectiveness on all levels of management.

Unmet supportive needs of cancer patients in an acute care hospital in Japan—a census study

Little research has been done on supportive needs of cancer patients in acute hospitals in Japan. This study aims to comprehensively assess the unmet supportive needs of hospitalized cancer patients, as well as literacy and utilization of appropriate professional care. All cancer patients (aged 20 to 80 years) who were hospitalized in a university hospital in Tokyo during the designated 3-day period between September 1 and October 31, 2007 were recruited for participation in the study. The M.D. Anderson Symptom Inventory, Brief Cancer-Related Worry Inventory, and Hospital Anxiety and Depression Scale were administered. Patients' knowledge and use of relevant services were evaluated. The results were compared with those of non-cancer patients in the same treatment settings. A total of 125 cancer patients and 59 non-cancer patients were enrolled. Cancer patients and non-cancer patients equally suffered from physical symptoms (15-26% had severe appetite loss, 18-19% had severe dry mouth, and 16-22% had severe pain); however, psychological distress of cancer patients exceeded that of non-cancer patients (28.0% vs 8.5%; p ≤ 0.05). Severe psychological distress was associated with severe worry about future prospects or interpersonal and social issues and presence of two or more severe symptoms. Two thirds of the patients with severe psychological distress knew about the psychiatric division, but only one third actually sought treatment. Needs related to psychological issues were more prevalent among cancer patients than among non-cancer patients, despite a similar level of physical distress. Special attention should be paid to cancer patients who worry over future prospects or interpersonal and social issues, and those who have two or more severe symptoms.

The accuracy of the Italian version of the Hypomania Checklist (HCL-32) for the screening of bipolar disorders and comparison with the Mood Disorder Questionnaire (MDQ) in a clinical sample

BackgroundThe study measured the accuracy of the Italian version of the Hypomania Checklist (HCL-32) for self-assessment as a screening instrument for bipolar disorder (BPD) in a psychiatric setting and compared results with a previous study, carried out in a comparable sample and in the same setting, using the Mood Disorder Questionnaire (MDQ).Methods123 consecutive subjects attending a psychiatric division were screened for BPD using the Italian translation of the HCL-32, and diagnostically interviewed with the SCID by physicians. The sample of the previous study using the MDQ consisted of 154 subjects.ResultsOn the basis of the SCID: 26 received a diagnosis of bipolar/schizoaffective disorder, 57 were diagnosed as having at least another psychiatric disorder in Axis-I, whilst 40 were unaffected by any type of psychiatric disorder. Comparing the bipolar with all other patients the HCL-32 showed a good accuracy: cut-off 8: sensitivity 0.92-specificity 0.48; cut-off 10: sensitivity 0.88-specificity 0.54; cut-off 12: sensitivity 0.85-specificity 0.61. The accuracy for BPD-II (10) remains good: cut-off 8: sensitivity 0.90-specificity 0.42; cut-off 10: sensitivity 0.80-specificity 0.47; cut-off 12: sensitivity 0.80-specificity 0.54. The comparison with the MDQ performance shows that both screening tools may show good results, but HCL-32 seems to be more sensitive in detecting BPD-II.ConclusionOur results seem to indicate good accuracy of HCL-32 as a screening instrument for BPD in a psychiatric setting, with a low rate of false negatives, and a fairly good degree of identification of BPD-II.

Anton Pavlovich Chekhov (1860-1904)

Back to table of contents Previous article Next article Images in PsychiatryFull AccessAnton Pavlovich Chekhov (1860–1904)Rajko Igić, M.D., Ph.D.Rajko IgićSearch for more papers by this author, M.D., Ph.D.Published Online:1 Dec 2005https://doi.org/10.1176/ajp.162.12.2248AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Chekhov’s stories and plays show deep psychological insight. He realized that scientific rationalism could not give us the answers to some important questions, such as, “What is the meaning of life?” Thus, he presented man as a victim in an absurd world.Chekhov graduated from medical school in 1884 and started working as a physician in a suburban Moscow hospital. Eight years later, he purchased the rundown Melikhovo estate 70 km south of Moscow. He lived there until his declining health due to lung tuberculosis forced him to move to the milder climate of Yalta.In Melikhovo, Chekhov saw hundreds of patients, made more than a thousand house calls, and fought against cholera and illiteracy (1). Although he practiced medicine by day, at night he wrote masterpieces—stories and two magnificent plays: The Seagull and Uncle Vanya. Although Chekhov was not a wealthy man, he did not charge his patients. In 1890, he made a journey across Siberia to Sakhalin Island, where Russian convicts were kept. The hardships of that journey and his 3-month sojourn on the island were frightful. His report of the trip includes a moving description of brutal beatings he witnessed that made such an impression on the Russian public that corporal punishment was abolished for women in 1897 and for men in 1904 (2).Chekhov created hundreds of characters who show weakness, passivity, and ineffectiveness. His stories (Tolstoy compared them to impressionist paintings) and his best plays (including Three Sisters and The Cherry Orchard) still strongly appeal to readers and theatergoers the world over. Chekhov’s numerous characters include an array of more than 30 medical doctors who are hindered by various problems and poor working conditions. In his story titled Ward No. 6, set in the psychiatric division of a provincial hospital, Dr. Ragin encounters a sparkling paranoid man named Gromov who has been confined for proclaiming that truth and justice must one day triumph. Ironically, Dr. Ragin is trapped by his superiors in his own ward, and after a beating by a nurse, he dies of a stroke. When the novelist Nikolay Leskov read this masterpiece, he said, “Ward No. 6 is Russia!” (3).Chekhov clearly showed that the symbiosis of the muse and Æsculapius may increase the writer’s capabilities. He wrote to a friend, “Medicine is my lawful wife, literature my mistress. When I tire of the one, I spend the night with the other. As long as it does not become a regular habit, it is not humdrum and neither of them suffers from my infidelity” (4). Thanks to his literary talent and his psychological approach, Chekhov improved both the modern story and the modern play.Address correspondence and reprint requests to Dr. Igić, John H. Stroger, Jr., Hospital of Cook County, 637 S. Wood, Rm. 427 DX, Chicago, IL 60612; [email protected] (e-mail). Photograph published with permission of the Granger Collection, New York. Anton Pavlovich Chekhov

Memories of Dr Elliott Jaques

AbstractElliott Jaques studied medicine, and later became a major in the Canadian Army. He acted as a liaison offier with the Psychiatric Division of the British Army under Brigadier JR Rees, and in this role he made contact with psychoanalysts who worked in the British Army. Several of these officers, along with Jaques and myself, trained as psychoanalysts. Jaques was one of the founder members of the Tavistock Institute of Human Relations. In 1961 Jaques was elected as Scientific Secretary of the British Psychoanalytic Society. In 1965 he was appointed Professor and Head of the School of Social Sciences at Brunel University. In 1967 he asked me to work as a part‐time senior lecturer in the School. Jaques was a prolific writer and became known to organizations world‐wide. He was a consultant to a number of institutions, and later to governments, including the Pentagon. In 1980 he left London for the USA. Copyright © 2005 John Wiley &amp; Sons, Ltd.

Relationship Between Criminal Arrest and Community Treatment History Among Patients With Bipolar Disorder

This study examined the relationship between criminal arrest and gender, substance use disorder, and use of community mental health services among patients with bipolar I disorder. Los Angeles County's computerized management information system was used to retrospectively identify all inmates with a DSM-IV diagnosis of bipolar I disorder who were evaluated over a seven-month period in the psychiatric division of Los Angeles County Jail and had a history of psychiatric hospitalization in the community. Patients without a history of arrest who were involuntarily hospitalized in the community and treated for bipolar I disorder over the same seven-month period served as a comparison group. The use of community mental health services that inmates received before their arrest was quantified and compared with the services that patients in the comparison group received before their involuntary hospitalization. Patients who had been arrested (N = 66) were more likely than patients in the comparison group (N = 52) to be male (55 percent compared with 31 percent) and to have a history of substance use disorder (76 percent compared with 19 percent) but were less likely to have a history of treatment while under a mental health conservatorship (8 percent compared with 29 percent). In contrast to patients in the comparison group, patients who had been arrested were hospitalized more frequently (a mean of 3.4 hospitalizations per year compared with a mean of 1.1 hospitalizations per year) and had a briefer average length of stay (a mean of 9.2 days compared with a mean of 16.4 days). In contrast to patients in the comparison group, patients who had been arrested were more likely to be male, to have comorbid substance use disorder, and to have a treatment history characterized by more frequent, briefer hospitalizations.

Clinical and legal correlates of inmates with bipolar disorder at time of criminal arrest.

In an effort to determine illness factors associated with criminality among bipolar patients, we identified bipolar arrestees housed in the psychiatric division of the Los Angeles County Jail who had a history of psychiatric treatment in the Los Angeles County community mental health system. Los Angeles County's computerized management information system was utilized to retrospectively identify all inmates evaluated over a 7-month period from July 1999 to Jan. 2000 with a DSM-IV diagnosis of bipolar I disorder, their symptoms at time of arrest, and the nature of community treatment preceding arrest. Criminal history was assessed using Sheriff's Department legal records. Demographic and clinical characteristics of these inmates were compared with characteristics present in a group of hospitalized bipolar patients without a history of arrest in Los Angeles County. Of the 66 inmates identified as having a clear diagnosis of bipolar disorder with previous community treatment in the Los Angeles County Mental Health system, the majority were manic (49/66, 74.2%) and psychotic (39/66, 59%) at time of arrest. Manic arrestees were recently released from community inpatient treatment and most were not involved in outpatient treatment postdischarge. The bipolar inmates had significantly higher rates of comorbid substance abuse than did the hospitalized bipolar patients without an arrest history (75.8% [50/66]) vs. 18.5% [10/54]). The results of this study suggest that manic symptoms place bipolar patients at significant risk for criminal offending and arrest. Intensive treatment intervention by the community mental health and criminal justice system may be needed, particularly in the immediate postmanic hospitalization period, in order to prevent incarceration of patients with bipolar disorder.

Women Alcoholics at Bellevue, 1918-1919

Data published in Science 's pages in a 1936 article about historical trends in alcoholism admissions at Bellevue Hospital in New York City are probably mistaken. The questionable data occur in a paper authored by alcoholism, vitamin, and cholesterol researcher Norman Jolliffe (1901–1961) [“The alcoholic admissions to Bellevue Hospital” 83 , 306 (1936)]. Jolliffe's paper reported a generally downward trend in the proportion of female (to male) Bellevue alcoholism admissions from 1902 to 1933—the latter, national prohibition's final year. The trend was punctuated however by a sudden spike in 1918 and 1919, when the proportion of female admissions virtually doubled to 41.8% and 39.5%, respectively. Jolliffe offered two guesses for the occurrence. First, it might have been “due in part to an increase of social drinking occasioned by entertaining soldiers embarking for and returning from overseas.” Second, the unhappiness caused by the war-time absence of men turned more women to drink. Jolliffe cleverly deduced that the absence of men, and not worry about men's safety in combat, explained the rise, incidentally, by noting that female admissions were almost as large in 1919 as in 1918, even though hostilities had ceased by the latter year. In 1990, I exchanged correspondence with the late Mark Keller, longtime editor of the Journal of Studies on Alcohol , who worked as Jolliffe's editorial and research assistant in the 1930s. Keller noted that a mixup had occurred in the collection of data for Jolliffe's Bellevue admissions paper. He explained that both of Jolliffe's hypotheses for the female admissions spike were moot because the increase in the proportion of female admissions never actually happened. A change in admissions-recording practices, he explained, was the source of the apparent spike. > The previous [pre-1918] and later [post-1919] statistics were filed by the famous Dr. Menas Sarcos Gregory. During the war he went into Government service. The deputy who substituted for him … did something different from Gregory. He filed “all” the alcoholic admissions in the entire Bellevue Hospital, whereas Gregory used to file only the Alcoholic Ward admissions, in the old days, and the Psychiatric Division admissions since it got its new building. This obviously accounted for the seeming increase of female admissions in those two years; for apparently there was a policy of admitting most drunken women to the general medical wards rather than to the ‘alcoholic ward’ in Psycho. Likely, too, that in the old Alcoholic Ward (pre-1930s) there wasn't much room for women.—This error in the 1936 Science paper had never been corrected. Keller's statement implies that more than the spike was awry in Jolliffe's admissions trend-lines. If the female admissions were underreported in years before and after 1918 and 1919, then both female admissions and, by extension, total admissions trends reported in Jolliffe's paper are likely problematic. Keller noted that he had intended on more than one occasion to write Science about the matter, to illustrate, he said, the “vagaries of hypothesizing,” but he apparently never got around to it. The data offered in Jolliffe's 60-year-old paper retain more than merely archaic interest. Figures relating to alcoholism admissions and alcohol consumption during national prohibition are used and of interest to, for example, both sides in the current national debate over drug decriminalization. (see, for example, E. A. Nadelmann, Letters, 1 Dec. 1989, p. 1104) I hope and trust that Keller and the good Dr. Jolliffe would have been relieved and pleased to see this little matter finally cleared up!

Brain morphology, dopamine, and eye-tracking abnormalities in first-episode schizophrenia. Prevalence and clinical correlates.

To characterize the pathophysiology of schizophrenia and to identify biologic markers in first-episode patients with no or little prior treatment exposure. Prospective study of an inception cohort. Psychiatric division of an academic medical center with a suburban metropolitan catchment area. 70 patients in their first episode of schizophrenia (77%) or schizoaffective disorder (23%) with no (70%) or limited prior neuroleptic exposure (30%), and 50 healthy volunteer control subjects. ASSESSMENT MEASURES: Demographic and clinical evaluations of natural history and psychopathology; methylphenidate hydrochloride and apomorphine hydrochloride stimulation tests as measures of central nervous system dopamine activity; brain magnetic resonance imaging; eye-tracking examinations. Preliminary analyses demonstrate that pathobiologic features previously identified in heterogeneous and primarily chronically ill patients are also present in subgroups during their first episode. These include psychotogenic response to methylphenidate (59%), abnormal growth hormone (GH) secretion (50%), abnormal brain morphology (31%), and eye-tracking dysfunction (51%). An association of pathobiologic variables with increased symptom severity and earlier age of onset was observed but not statistically significant. The strongest associations among biologic variables were for the following: GH secretion and psychotogenic response to methylphenidate, which may reflect increased dopamine agonist neural activity; decreased GH response to apomorphine and third-ventricle enlargement, which may represent a neuropathologic correlate of anterior pituitary abnormalities; and morphologic abnormalities of the medial temporal lobe and third ventricle were associated with normal eye tracking, suggesting that these pathobiologic features are mediated by distinct processes. These phenomena appear to be a consequence of the disease rather than the effects of chronicity, drug treatment, or institutionalization. It remains to be determined if these biologic phenomena will remain stable over time or change with disease progression. A companion article examines the clinical significance of these findings.

The management of hostages after release∗

The recent release of British and American hostages held by fundamentalist Islamic groups in Lebanon has received national and international publicity. The Psychiatric Division of the Royal Air Force Medical Service has been involved with the management of released British nationals and others but, in the interests of the hostages and their families, has delayed public discussion of the matter. From the British and American viewpoint the recent hostage crisis in the Lebanon has now resolved. It therefore now seems appropriate to describe in general terms the principles upon which early management was based.