Joseph D. Bloom

An empirical view of patients exercising their right to refuse treatment

In recent years heated debate in the law-mental health arena has centered on the right to refuse treatment. Similar to previous important interactions in the field, this one caught many in psychiatry by surprise. Using a theoretical model based on mourning (Kubler-Ross, 1969), after denying for years that a patient’s right to refuse treatment was even an issue for consideration, many psychiatrists were shocked and outraged that this also was to be the subject of scrutiny. Legal “bargaining” in the courts confirmed that patients did indeed have the right to refuse treatment. There was despair and fear of destruction of our institutions and a heralded return to Bedlam. We have now moved into a period of acceptance, adjustment, and accommodation. Attention has focused on the specifics of how this right can be assured without causing undue harm to our patients or creating havoc in our psychiatric institutions. In this paper we briefly review the right to refuse treatment from a national perspective. We then describe Oregon’s new informed consent rule which is the administrative procedure for managing involuntary patients refusing treatment. We describe the characteristics and refusal patterns of 82 state hospital patients whose refusal of treatment in 1983 was managed with this new procedure. We conclude with a discussion of our results, highlighting major issues brought to the fore by the Oregon procedure.

After Oregon's insanity defense:: A comparison of conditional release and hospitalization☆

Abstract This paper is one in a series of reports on the characteristics of persons committed to the Oregon Psychiatric Security Review Board (PSRB) and their treatment and disposition while subject to its jurisdiction. For the purpose of this discussion, we have focused on conditional release and attempt to answer a number of questions. How do the individuals who are placed in the community differ from those who remain hospitalized? Do the two mechanisms of conditional release in this system, by judges or the PSRB, differ in terms of the kinds of people that they are likely to release? Lastly, what features distinguish those individuals who manage to succeed in their release plans from those who do not?

The prevalence and significance of medical illness among chronically mentally ill outpatients.

The prevalence and significance of medical illnesses were examined in a sample of chronically mentally ill patients from an urban community mental health program. Eighty-eight percent had at least one significant medical illness, 51% had at least one previously undiagnosed illness and 53% were judged to be in need of some form of medical attention. The bulk of these illnesses were typical of primary care problems. In terms of causal significance, nearly as many medical illnesses appeared to be the result of the psychiatric disorder (18%) as vice versa (22%). Community mental health programs should make provisions for the medical needs of patients in comprehensive management programs.

Diagnostic Efforts Regarding Women in Oregon's Prison System: A Preliminary Report

This study examined 91 women entering Oregons prison system using a combination of psychometric testing and clinical interviews, to assess their need for mental health care. The incidence of mental disorders was high in this population and rarely did the women receive only one diagnosis. Substance abuse/dependence (91%) and affective disorders (42%) were the most prevalent diagnoses that co-occurred in the majority of cases. Psychotic disorders were not often identified. Our study points to two overlapping groups of women who are need of treatment while in prison, those with affective and/or substance abuse problems.

Weapons possession by patients in a university emergency department

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.

The pregnant psychiatric inpatient: A missed opportunity

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.

A comparison study of career satisfaction and emotional states between primary care and speciality residents

Objective  To evaluate career satisfaction, emotional states and positive and negative experiences among residents in primary care and speciality programmes in 1 academic medical centre prior to the implementation of the Accreditation Council for Graduate Medical Educations (ACGME) duty hour requirements.

The incarceration revolution: the abandonment of the seriously mentally ill to our jails and prisons.

It is well known that today jails and prisons house many seriously mentally ill citizens who in prior decades have been treated in mental hospitals and community mental health programs. This paper begins with a brief review of the history of support for mental health programs at the federal level and then, using the State of Oregon as an example, describes the new state era of mental health services which is characterized by the increasing use of the criminal justice system as a cornerstone of the treatment of many seriously and chronically mentally ill individuals. Are there any solutions to our current dilemma? The paper ends with this question, and the reader must determine if any of the suggestions posed in this discussion are realistic and/or feasible given the current fiscal and political climate.

Women in Oregon's Insanity Defense System

This article examines and compares women and men who successfully used the insanity defense in Oregon over a four and a half–year period. There was no significant difference between men and women in diagnoses or types of trial proceedings. A significantly greater percentage of women committed homicides, but since women also committed a greater percentage of misdemeanors, the average seriousness of crimes did not differ significantly between men and women. Nonetheless, women were released from hospitalization more frequently and after shorter stays than men. The authors discuss possible explanations for this apparent bias in favor of women.

A 36-year history of fatal road rage in Marion County, Oregon: 1963-1998.

This paper documents the 36-year history, with five examples, of fatal road rage in Marion County, Oregon. Relevant details (all that were available) from each case are presented. Alcohol intoxication was present in four of our five cases. We include two deaths by gunshot at close range, two deaths as a result of a motor vehicle traffic accident, and one natural death. All subjects were males. Three were Caucasian and two were Hispanic. The three subjects in Cases 1, 2 and 3 were complete strangers to the occupants of the other involved vehicles. The subjects in Cases 4 and 5 (along with the occupants of their own vehicles) were acquaintances of the occupants of the involved vehicle. There appears to be no previous forensic, medical or psychiatric literature on road rage as such. We present an initial psychiatric evaluation of the perpetrators of this type of fatal assault. There are no specific statutes in Oregon, at the state or county levels, regarding road rage. However, the city of Gresham, Oregon, recently enacted an ordinance regarding road rage. We stress the need for further study of this phenomenon, especially through the use of the psychological-psychiatric autopsy.