New York under the Rivers decision: an epidemiologic study of drug treatment refusal

Article Abstract:

Several legal decisions have upheld the right of psychiatric patients to refuse medication regardless of their commitment status until due process can be served. There are two components of due process: rights-driven and treatment-driven. Rights-driven due process refers to the investigation of one's competence to make a decision regarding one's own treatment, and is judicially determined. Treatment-driven due process relies on clinical review of evidence for and against involuntary treatment and is often done in-house. The Rivers v. Katz decision in New York in 1986 attempted to bring these two elements of due process together. The courts were given the power not only to determine competency, a power that they had before, but also the power to rule on the appropriateness of treatment after review of a physician's request. A review of the impact of this decision during a one-year period is presented here. There were 499 applications to the courts for involuntary treatment of psychiatric patients during this period. The physician's request for treatment was obtained for each patient, the final order of the court was obtained, and medication administration records were reviewed. The patients who refused medication were more likely to be aged 30 years to 59 years than the average patient was, and they tended to be involuntarily admitted or criminally committed. They also tended to be acutely ill, hospitalized for between 91 days and 2 years, and suffering from a major psychosis such as schizophrenia. Nearly one-third of the applications were withdrawn before the courts acted, but the reasons for withdrawal were not evident, and these patients were twice as likely to be discharged without follow-up as patients who underwent court review. Seventy-two percent of the applications were reviewed by the court, and approval of the physician's request was made in 91 percent of the reviewed cases. Significantly more applications to treat women than men were denied, but there were no differences in other sociodemographic factors. It is recommended that a two-tier system be used, with in-house clinical review preceding judicial review. (Consumer Summary produced by Reliance Medical Information, Inc.)

Laws, regulations and rules, Drug therapy, Right to refuse treatment, Treatment refusal

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Acute manic episodes in pregnancy

Article Abstract:

A 33-year-old pregnant woman was admitted to the hospital for hypomania and diabetes mellitus. Hypomania is a bipolar disorder which the patient first encountered when she was 28 years old and after her second pregnancy. She has been treated several times for acute mania with mood-stabilizing drugs. However, owing to her present condition, physicians discontinued some of the drugs because of the risks they pose to pregnancy. Instead, her treatment included only a combination of valproate and chlorpromazine and bilateral electroconvulsive therapy.

Psychological aspects, Usage, Pregnancy, Electroconvulsive therapy, Electroshock, Bipolar disorder

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