Residents/Training

The measure of a country’s greatness, Mahatma Gandhi said, should be based on how well it cares for its most vulnerable. Recently, I had the opportunity to work with members of a vulnerable population: men and women who have a mental illness and languish in jails and prisons around the country. My experience was eye-opening and heartbreaking.

Widespread incarceration of the mentally ill in a developed country such as the United States should be a national embarrassment. But this tragedy, which has reached an epidemic level, has been effectively shut out of the national conversation.

The problem has grown, and is enormous
By the estimate of the U.S. Department of Justice, more than one-half of people incarcerated in the United States are mentally ill and approximately 20% suffer from a serious mental illness.^1,2 In fact, there are now 3 times as many mentally ill people in jail and prison as there are occupying psychiatric beds in hospitals.³ These numbers represent a considerable increase over the past 6 decades, and can be attributed to 2 major factors:

• A program of deinstitutionalization set in motion by the federal government in the 1950s called for shuttering of state psychiatric facilities around the country. This was a period of renewed national discourse on civil rights; for many people, the practice of institutionalization was considered a violation of civil rights. (Coincidentally, chlorpromazine was introduced about this time, and many experts believed that the drug would revolutionize outpatient management of psychiatric disorders.)
• More recently, heavy criminal penalties have been attached to convictions for possession and distribution of illegal substances—part of the government’s “war on drugs.”

As a consequence of these programs and policies, the United States has come full circle—routinely incarcerating the mentally ill as it did in the early 19th century, before reforms were initiated in response to the lobbying efforts of activist Dorothea Dix and her contemporaries.

My distressing, eye-opening experience
The time I spent with the incarcerated mentally ill was limited to a 6-month period at a county jail during residency. Yet the contrast between services provided to this population and those that are available to people in the community was immediately evident—and stark. The sheer number of adults in jails and prisons who require mental health care is such that the ratio of patients to psychiatrists, psychologists, and other mental health clinicians is shockingly skewed.

It does not take years of experience to figure out that a brief interview with an 18-year-old who is being jailed for the first time, has never seen a psychiatrist, and suffers panic attacks (or hallucinations, or suicidal thoughts) is a less-than-ideal clinical situation. Making that situation even more hazardous is that inmates have a high risk of suicide, particularly in the first 24 to 48 hours of incarceration.⁴

Other ethical issues arose during my stint in the correctional system: My patients frequently would be charged with prison-rule violations (there is evidence that mentally ill inmates are more likely to be charged with such violations²); on many such occasions, they would be placed in solitary confinement (“the hole”), a practice the United Nations has called “cruel, inhuman, and degrading: for the mentally ill⁵ and that, in turn, exacerbates the inmate’s psychiatric illness.^6-11

Last, there are restrictions on the types of formulations of medications that can be prescribed, involuntary treatment, and other critical aspects of care that make the experience of providing care in this system frustrating for mental health providers.

Are there solutions?
One way to tackle this crisis might be to insert more psychiatrists and psychologists into the correctional system. A more sensible approach, however, would be to tackle the root cause and divert the mentally ill away from incarceration and into treatment—moving from a model of retribution and incapacitation to one of rehabilitation. For example:

• Several counties nationwide have adopted diversion programs that include so-called mental health courts and drug courts, with encouraging results¹²
• Police departments are establishing Crisis Intervention Teams
• Assisted outpatient treatment programs are growing in popularity.

Far more needs to be done, however. In the absence of a national debate on the problem of the incarcerated mentally ill, there is real risk that this population will continue to be ignored and that our mental health care infrastructure will remain inadequate for meeting their need for services.

The measure of a country’s greatness, Mahatma Gandhi said, should be based on how well it cares for its most vulnerable. Recently, I had the opportunity to work with members of a vulnerable population: men and women who have a mental illness and languish in jails and prisons around the country. My experience was eye-opening and heartbreaking.

Widespread incarceration of the mentally ill in a developed country such as the United States should be a national embarrassment. But this tragedy, which has reached an epidemic level, has been effectively shut out of the national conversation.

The problem has grown, and is enormous
By the estimate of the U.S. Department of Justice, more than one-half of people incarcerated in the United States are mentally ill and approximately 20% suffer from a serious mental illness.^1,2 In fact, there are now 3 times as many mentally ill people in jail and prison as there are occupying psychiatric beds in hospitals.³ These numbers represent a considerable increase over the past 6 decades, and can be attributed to 2 major factors:

• A program of deinstitutionalization set in motion by the federal government in the 1950s called for shuttering of state psychiatric facilities around the country. This was a period of renewed national discourse on civil rights; for many people, the practice of institutionalization was considered a violation of civil rights. (Coincidentally, chlorpromazine was introduced about this time, and many experts believed that the drug would revolutionize outpatient management of psychiatric disorders.)
• More recently, heavy criminal penalties have been attached to convictions for possession and distribution of illegal substances—part of the government’s “war on drugs.”

As a consequence of these programs and policies, the United States has come full circle—routinely incarcerating the mentally ill as it did in the early 19th century, before reforms were initiated in response to the lobbying efforts of activist Dorothea Dix and her contemporaries.

My distressing, eye-opening experience
The time I spent with the incarcerated mentally ill was limited to a 6-month period at a county jail during residency. Yet the contrast between services provided to this population and those that are available to people in the community was immediately evident—and stark. The sheer number of adults in jails and prisons who require mental health care is such that the ratio of patients to psychiatrists, psychologists, and other mental health clinicians is shockingly skewed.

It does not take years of experience to figure out that a brief interview with an 18-year-old who is being jailed for the first time, has never seen a psychiatrist, and suffers panic attacks (or hallucinations, or suicidal thoughts) is a less-than-ideal clinical situation. Making that situation even more hazardous is that inmates have a high risk of suicide, particularly in the first 24 to 48 hours of incarceration.⁴

Other ethical issues arose during my stint in the correctional system: My patients frequently would be charged with prison-rule violations (there is evidence that mentally ill inmates are more likely to be charged with such violations²); on many such occasions, they would be placed in solitary confinement (“the hole”), a practice the United Nations has called “cruel, inhuman, and degrading: for the mentally ill⁵ and that, in turn, exacerbates the inmate’s psychiatric illness.^6-11

Last, there are restrictions on the types of formulations of medications that can be prescribed, involuntary treatment, and other critical aspects of care that make the experience of providing care in this system frustrating for mental health providers.

Are there solutions?
One way to tackle this crisis might be to insert more psychiatrists and psychologists into the correctional system. A more sensible approach, however, would be to tackle the root cause and divert the mentally ill away from incarceration and into treatment—moving from a model of retribution and incapacitation to one of rehabilitation. For example:

• Several counties nationwide have adopted diversion programs that include so-called mental health courts and drug courts, with encouraging results¹²
• Police departments are establishing Crisis Intervention Teams
• Assisted outpatient treatment programs are growing in popularity.

Far more needs to be done, however. In the absence of a national debate on the problem of the incarcerated mentally ill, there is real risk that this population will continue to be ignored and that our mental health care infrastructure will remain inadequate for meeting their need for services.

The measure of a country’s greatness, Mahatma Gandhi said, should be based on how well it cares for its most vulnerable. Recently, I had the opportunity to work with members of a vulnerable population: men and women who have a mental illness and languish in jails and prisons around the country. My experience was eye-opening and heartbreaking.

Widespread incarceration of the mentally ill in a developed country such as the United States should be a national embarrassment. But this tragedy, which has reached an epidemic level, has been effectively shut out of the national conversation.

The problem has grown, and is enormous
By the estimate of the U.S. Department of Justice, more than one-half of people incarcerated in the United States are mentally ill and approximately 20% suffer from a serious mental illness.^1,2 In fact, there are now 3 times as many mentally ill people in jail and prison as there are occupying psychiatric beds in hospitals.³ These numbers represent a considerable increase over the past 6 decades, and can be attributed to 2 major factors:

• A program of deinstitutionalization set in motion by the federal government in the 1950s called for shuttering of state psychiatric facilities around the country. This was a period of renewed national discourse on civil rights; for many people, the practice of institutionalization was considered a violation of civil rights. (Coincidentally, chlorpromazine was introduced about this time, and many experts believed that the drug would revolutionize outpatient management of psychiatric disorders.)
• More recently, heavy criminal penalties have been attached to convictions for possession and distribution of illegal substances—part of the government’s “war on drugs.”

As a consequence of these programs and policies, the United States has come full circle—routinely incarcerating the mentally ill as it did in the early 19th century, before reforms were initiated in response to the lobbying efforts of activist Dorothea Dix and her contemporaries.

My distressing, eye-opening experience
The time I spent with the incarcerated mentally ill was limited to a 6-month period at a county jail during residency. Yet the contrast between services provided to this population and those that are available to people in the community was immediately evident—and stark. The sheer number of adults in jails and prisons who require mental health care is such that the ratio of patients to psychiatrists, psychologists, and other mental health clinicians is shockingly skewed.

It does not take years of experience to figure out that a brief interview with an 18-year-old who is being jailed for the first time, has never seen a psychiatrist, and suffers panic attacks (or hallucinations, or suicidal thoughts) is a less-than-ideal clinical situation. Making that situation even more hazardous is that inmates have a high risk of suicide, particularly in the first 24 to 48 hours of incarceration.⁴

Other ethical issues arose during my stint in the correctional system: My patients frequently would be charged with prison-rule violations (there is evidence that mentally ill inmates are more likely to be charged with such violations²); on many such occasions, they would be placed in solitary confinement (“the hole”), a practice the United Nations has called “cruel, inhuman, and degrading: for the mentally ill⁵ and that, in turn, exacerbates the inmate’s psychiatric illness.^6-11

Last, there are restrictions on the types of formulations of medications that can be prescribed, involuntary treatment, and other critical aspects of care that make the experience of providing care in this system frustrating for mental health providers.

Are there solutions?
One way to tackle this crisis might be to insert more psychiatrists and psychologists into the correctional system. A more sensible approach, however, would be to tackle the root cause and divert the mentally ill away from incarceration and into treatment—moving from a model of retribution and incapacitation to one of rehabilitation. For example:

• Several counties nationwide have adopted diversion programs that include so-called mental health courts and drug courts, with encouraging results¹²
• Police departments are establishing Crisis Intervention Teams
• Assisted outpatient treatment programs are growing in popularity.

Far more needs to be done, however. In the absence of a national debate on the problem of the incarcerated mentally ill, there is real risk that this population will continue to be ignored and that our mental health care infrastructure will remain inadequate for meeting their need for services.

Some practitioners of medicine—including psychiatrists—might equate “psychosis” with incapacity, but that isn’t necessarily true. Even patients who, by most measures, are deemed psychotic might be capable of making wise and thoughtful decisions about their life. The case I describe in this article demonstrates that fact.

While rotating on a busy consultation service, I was asked to evaluate the capacity of a woman who had a diagnosis of schizophrenia and was being seen for worsening auditory hallucinations and progressive weight loss. She had a complicated medical course that eventually led to multiple requests to the consult team for a capacity evaluation.

The question of capacity in this patient, and in the psychiatric population generally, motivated me to review the literature, because the assumption by many on the medical teams involved in this patient’s care was that psychiatric patients do not have the capacity to participate in their own care. My goal here is to clarify the misconceptions in regard to this situation.

CASE REPORT
Schizophrenia, weight loss, back pain
Ms. V, age 67, a resident of a group home for the past 6 years, was brought to the emergency department (ED) because of weight loss and auditory hallucinations that had developed during the past few months. She had a history of paranoid schizophrenia that included several psychiatric hospitalizations but no known medical history.

The patient appeared cachectic and dehydrated. When approached, she was pleasant and reported hearing voices of the “devil.”

“They are not scary,” she confided. “They talk to me about art and literature.”

Over the past 6 months, Ms. V had lost 60 lb; she was now bedridden because of back pain. Collateral information obtained from staff members at the group home indicated that she had refused to get out of bed, and only intermittently took her medications or ate meals during the past few months. In general, however, she had been relatively stable over the course of her psychiatric illness, was adherent to psychiatric treatment, and had had no psychiatric hospitalizations in the past 3 decades.

Ominous development. Although the ED staff was convinced that Ms. V needed psychiatric admission, we (the consult team) first requested a detailed medical workup, including imaging studies. A CT scan showed multiple metastatic foci throughout her spine. She was admitted to the medical service.

Respiratory distress developed; her condition deteriorated. Numerous capacity consults were requested because she refused a medical workup or to sign do-not-resuscitate and do-not-intubate orders. Each time an evaluation was performed, Ms. V was deemed by various clinicians on the consult service to have decision-making capacity.

The patient grew unhappy with the staff’s insistence that she undergo more tests regardless of her stated wishes. The palliative care service determined that further workup would not benefit her medically: Ms. V’s condition would be grave and her prognosis poor regardless of what treatment she received.

The medical team continued to believe that, because that this patient had a mental illness and was actively hallucinating, she did not have the capacity to refuse any proposed treatments and tests.

What is capacity?
Capacity is an assessment of a person’s ability to make rational decisions. This includes the ability to understand, appreciate, and manipulate information in reaching such decisions. Determining whether a patient has the capacity to accept or refuse treatment is a medical decision that any physician can make; however, consultation−liaison psychiatrists are the experts who often are involved in this activity, particularly in patients who have a psychiatric comorbidity.

Capacity is evaluated by assessing 4 standards; that is, whether a patient can:

• communicate choice about proposed treatment
• understand her (his) medical situation
• appreciate the situation and its consequences
• manipulate information to reach a rational decision.^1-3
• manipulate information to reach a rational decision.
   

CASE REPORT continued
Although Ms. V’s health was deteriorating and her auditory hallucinations were becoming worse, she appeared insightful about her medical problems, understood her prognosis, and wanted comfort care. She understood that having multiple metastases meant a poor prognosis, and that a biopsy might yield a medical diagnosis. She stated, “If it were caught earlier and I was better able to tolerate treatment, it would make sense to know for sure, but now it doesn’t make sense. I just want to have no pain in my end.”
 

Misconceptions
In a study by Ganzini et al,^4,5 395 consultation−liaison psychiatrists, geriatricians, and geriatric psychologists responded to a survey in which they rated types of misunderstandings by clinicians who refer patients for assessment of decision-making capacity. Seventy percent reported that it is common that, when a patient has a mental illness such as schizophrenia, practitioners think that the patient lacks capacity to make medical decisions. However, results of a meta-analysis by Jeste et al,⁶ in which the magnitude of impairment of decisional capacity in patients with schizophrenia was assessed in comparison to that of normal subjects, suggest that the presence of schizophrenia does not necessarily mean the patient has impaired capacity.

Voluntary participation in research. Many patients with schizophrenia volunteer to participate in clinical trials even when they are acutely psychotic and admitted to a psychiatric hospital. Given the importance placed on participants’ voluntary informed consent as a prerequisite for ethical conduct of research, the cognitive and emotional impairments associated with schizophrenia raise questions about patients’ capacity to consent.

As is true in other areas of functional capacity, the ability of patients with schizophrenia to make competent decisions relates more to their overall cognitive functioning than to the presence or absence of specific symptoms of the disorder.⁷ Documentation of longitudinal consent-related abilities among research participants with schizophrenia in the long-term Clinical Antipsychotic Trials of Intervention Effectiveness study indicated that most participants had stable or improved consent-related abilities. Although almost 25% of participants experienced substantial worsening, only 4% fell below the study’s capacity threshold for enrollment.⁸

What I learned from Ms. V
A diagnosis of schizophrenia does not automatically render a person unable to make decisions about medical care. Even patients who have severe mental illness might have significant intact areas of reality testing. Ethically, it is important to at least consider that the chronically mentally ill can understand treatment options and express consistent choices.

Healthcare providers might tend to exclude psychiatric patients from end-of-life decisions because they (1) are worried about the emotional fragility of such patients and (2) assume that patients lack capacity to participate in making such important decisions. The case presented here is an example of a patient with a severe psychiatric diagnosis being able to participate in her care despite her mental state.

Some practitioners of medicine—including psychiatrists—might equate “psychosis” with incapacity, but that isn’t necessarily true. Even patients who, by most measures, are deemed psychotic might be capable of making wise and thoughtful decisions about their life. The case I describe in this article demonstrates that fact.

While rotating on a busy consultation service, I was asked to evaluate the capacity of a woman who had a diagnosis of schizophrenia and was being seen for worsening auditory hallucinations and progressive weight loss. She had a complicated medical course that eventually led to multiple requests to the consult team for a capacity evaluation.

The question of capacity in this patient, and in the psychiatric population generally, motivated me to review the literature, because the assumption by many on the medical teams involved in this patient’s care was that psychiatric patients do not have the capacity to participate in their own care. My goal here is to clarify the misconceptions in regard to this situation.

CASE REPORT
Schizophrenia, weight loss, back pain
Ms. V, age 67, a resident of a group home for the past 6 years, was brought to the emergency department (ED) because of weight loss and auditory hallucinations that had developed during the past few months. She had a history of paranoid schizophrenia that included several psychiatric hospitalizations but no known medical history.

The patient appeared cachectic and dehydrated. When approached, she was pleasant and reported hearing voices of the “devil.”

“They are not scary,” she confided. “They talk to me about art and literature.”

Over the past 6 months, Ms. V had lost 60 lb; she was now bedridden because of back pain. Collateral information obtained from staff members at the group home indicated that she had refused to get out of bed, and only intermittently took her medications or ate meals during the past few months. In general, however, she had been relatively stable over the course of her psychiatric illness, was adherent to psychiatric treatment, and had had no psychiatric hospitalizations in the past 3 decades.

Ominous development. Although the ED staff was convinced that Ms. V needed psychiatric admission, we (the consult team) first requested a detailed medical workup, including imaging studies. A CT scan showed multiple metastatic foci throughout her spine. She was admitted to the medical service.

Respiratory distress developed; her condition deteriorated. Numerous capacity consults were requested because she refused a medical workup or to sign do-not-resuscitate and do-not-intubate orders. Each time an evaluation was performed, Ms. V was deemed by various clinicians on the consult service to have decision-making capacity.

The patient grew unhappy with the staff’s insistence that she undergo more tests regardless of her stated wishes. The palliative care service determined that further workup would not benefit her medically: Ms. V’s condition would be grave and her prognosis poor regardless of what treatment she received.

The medical team continued to believe that, because that this patient had a mental illness and was actively hallucinating, she did not have the capacity to refuse any proposed treatments and tests.

What is capacity?
Capacity is an assessment of a person’s ability to make rational decisions. This includes the ability to understand, appreciate, and manipulate information in reaching such decisions. Determining whether a patient has the capacity to accept or refuse treatment is a medical decision that any physician can make; however, consultation−liaison psychiatrists are the experts who often are involved in this activity, particularly in patients who have a psychiatric comorbidity.

Capacity is evaluated by assessing 4 standards; that is, whether a patient can:

• communicate choice about proposed treatment
• understand her (his) medical situation
• appreciate the situation and its consequences
• manipulate information to reach a rational decision.^1-3
• manipulate information to reach a rational decision.
   

CASE REPORT continued
Although Ms. V’s health was deteriorating and her auditory hallucinations were becoming worse, she appeared insightful about her medical problems, understood her prognosis, and wanted comfort care. She understood that having multiple metastases meant a poor prognosis, and that a biopsy might yield a medical diagnosis. She stated, “If it were caught earlier and I was better able to tolerate treatment, it would make sense to know for sure, but now it doesn’t make sense. I just want to have no pain in my end.”
 

Misconceptions
In a study by Ganzini et al,^4,5 395 consultation−liaison psychiatrists, geriatricians, and geriatric psychologists responded to a survey in which they rated types of misunderstandings by clinicians who refer patients for assessment of decision-making capacity. Seventy percent reported that it is common that, when a patient has a mental illness such as schizophrenia, practitioners think that the patient lacks capacity to make medical decisions. However, results of a meta-analysis by Jeste et al,⁶ in which the magnitude of impairment of decisional capacity in patients with schizophrenia was assessed in comparison to that of normal subjects, suggest that the presence of schizophrenia does not necessarily mean the patient has impaired capacity.

Voluntary participation in research. Many patients with schizophrenia volunteer to participate in clinical trials even when they are acutely psychotic and admitted to a psychiatric hospital. Given the importance placed on participants’ voluntary informed consent as a prerequisite for ethical conduct of research, the cognitive and emotional impairments associated with schizophrenia raise questions about patients’ capacity to consent.

As is true in other areas of functional capacity, the ability of patients with schizophrenia to make competent decisions relates more to their overall cognitive functioning than to the presence or absence of specific symptoms of the disorder.⁷ Documentation of longitudinal consent-related abilities among research participants with schizophrenia in the long-term Clinical Antipsychotic Trials of Intervention Effectiveness study indicated that most participants had stable or improved consent-related abilities. Although almost 25% of participants experienced substantial worsening, only 4% fell below the study’s capacity threshold for enrollment.⁸

What I learned from Ms. V
A diagnosis of schizophrenia does not automatically render a person unable to make decisions about medical care. Even patients who have severe mental illness might have significant intact areas of reality testing. Ethically, it is important to at least consider that the chronically mentally ill can understand treatment options and express consistent choices.

Healthcare providers might tend to exclude psychiatric patients from end-of-life decisions because they (1) are worried about the emotional fragility of such patients and (2) assume that patients lack capacity to participate in making such important decisions. The case presented here is an example of a patient with a severe psychiatric diagnosis being able to participate in her care despite her mental state.

Some practitioners of medicine—including psychiatrists—might equate “psychosis” with incapacity, but that isn’t necessarily true. Even patients who, by most measures, are deemed psychotic might be capable of making wise and thoughtful decisions about their life. The case I describe in this article demonstrates that fact.

While rotating on a busy consultation service, I was asked to evaluate the capacity of a woman who had a diagnosis of schizophrenia and was being seen for worsening auditory hallucinations and progressive weight loss. She had a complicated medical course that eventually led to multiple requests to the consult team for a capacity evaluation.

The question of capacity in this patient, and in the psychiatric population generally, motivated me to review the literature, because the assumption by many on the medical teams involved in this patient’s care was that psychiatric patients do not have the capacity to participate in their own care. My goal here is to clarify the misconceptions in regard to this situation.

CASE REPORT
Schizophrenia, weight loss, back pain
Ms. V, age 67, a resident of a group home for the past 6 years, was brought to the emergency department (ED) because of weight loss and auditory hallucinations that had developed during the past few months. She had a history of paranoid schizophrenia that included several psychiatric hospitalizations but no known medical history.

The patient appeared cachectic and dehydrated. When approached, she was pleasant and reported hearing voices of the “devil.”

“They are not scary,” she confided. “They talk to me about art and literature.”

Over the past 6 months, Ms. V had lost 60 lb; she was now bedridden because of back pain. Collateral information obtained from staff members at the group home indicated that she had refused to get out of bed, and only intermittently took her medications or ate meals during the past few months. In general, however, she had been relatively stable over the course of her psychiatric illness, was adherent to psychiatric treatment, and had had no psychiatric hospitalizations in the past 3 decades.

Ominous development. Although the ED staff was convinced that Ms. V needed psychiatric admission, we (the consult team) first requested a detailed medical workup, including imaging studies. A CT scan showed multiple metastatic foci throughout her spine. She was admitted to the medical service.

Respiratory distress developed; her condition deteriorated. Numerous capacity consults were requested because she refused a medical workup or to sign do-not-resuscitate and do-not-intubate orders. Each time an evaluation was performed, Ms. V was deemed by various clinicians on the consult service to have decision-making capacity.

The patient grew unhappy with the staff’s insistence that she undergo more tests regardless of her stated wishes. The palliative care service determined that further workup would not benefit her medically: Ms. V’s condition would be grave and her prognosis poor regardless of what treatment she received.

The medical team continued to believe that, because that this patient had a mental illness and was actively hallucinating, she did not have the capacity to refuse any proposed treatments and tests.

What is capacity?
Capacity is an assessment of a person’s ability to make rational decisions. This includes the ability to understand, appreciate, and manipulate information in reaching such decisions. Determining whether a patient has the capacity to accept or refuse treatment is a medical decision that any physician can make; however, consultation−liaison psychiatrists are the experts who often are involved in this activity, particularly in patients who have a psychiatric comorbidity.

Capacity is evaluated by assessing 4 standards; that is, whether a patient can:

• communicate choice about proposed treatment
• understand her (his) medical situation
• appreciate the situation and its consequences
• manipulate information to reach a rational decision.^1-3
• manipulate information to reach a rational decision.
   

CASE REPORT continued
Although Ms. V’s health was deteriorating and her auditory hallucinations were becoming worse, she appeared insightful about her medical problems, understood her prognosis, and wanted comfort care. She understood that having multiple metastases meant a poor prognosis, and that a biopsy might yield a medical diagnosis. She stated, “If it were caught earlier and I was better able to tolerate treatment, it would make sense to know for sure, but now it doesn’t make sense. I just want to have no pain in my end.”
 

Misconceptions
In a study by Ganzini et al,^4,5 395 consultation−liaison psychiatrists, geriatricians, and geriatric psychologists responded to a survey in which they rated types of misunderstandings by clinicians who refer patients for assessment of decision-making capacity. Seventy percent reported that it is common that, when a patient has a mental illness such as schizophrenia, practitioners think that the patient lacks capacity to make medical decisions. However, results of a meta-analysis by Jeste et al,⁶ in which the magnitude of impairment of decisional capacity in patients with schizophrenia was assessed in comparison to that of normal subjects, suggest that the presence of schizophrenia does not necessarily mean the patient has impaired capacity.

Voluntary participation in research. Many patients with schizophrenia volunteer to participate in clinical trials even when they are acutely psychotic and admitted to a psychiatric hospital. Given the importance placed on participants’ voluntary informed consent as a prerequisite for ethical conduct of research, the cognitive and emotional impairments associated with schizophrenia raise questions about patients’ capacity to consent.

As is true in other areas of functional capacity, the ability of patients with schizophrenia to make competent decisions relates more to their overall cognitive functioning than to the presence or absence of specific symptoms of the disorder.⁷ Documentation of longitudinal consent-related abilities among research participants with schizophrenia in the long-term Clinical Antipsychotic Trials of Intervention Effectiveness study indicated that most participants had stable or improved consent-related abilities. Although almost 25% of participants experienced substantial worsening, only 4% fell below the study’s capacity threshold for enrollment.⁸

What I learned from Ms. V
A diagnosis of schizophrenia does not automatically render a person unable to make decisions about medical care. Even patients who have severe mental illness might have significant intact areas of reality testing. Ethically, it is important to at least consider that the chronically mentally ill can understand treatment options and express consistent choices.

Healthcare providers might tend to exclude psychiatric patients from end-of-life decisions because they (1) are worried about the emotional fragility of such patients and (2) assume that patients lack capacity to participate in making such important decisions. The case presented here is an example of a patient with a severe psychiatric diagnosis being able to participate in her care despite her mental state.

CASE REPORT Evaluation for renal transplant

Mr. B, age 21, who has a diagnosis of autism spectrum disorder and an IQ comparable to that of a 4-year-old, is referred for evaluation of his candidacy for renal transplant.

A few months earlier, Mr. B pulled out his temporary dialysis catheter. Now, he receives hemodialysis through an arteriovenous fistula in the arm, but requires constant supervision during dialysis.

At evaluation, Mr. B is accompanied by his parents and his older sister, who have been providing day-to-day care for him. They appear fully committed to his well-being.

Mr. B does not have a living donor.

Needed: Assessment of adaptive functioning
DSM-5 defines intellectual disability as a disorder with onset during the developmental period. It includes deficits of intellectual and adaptive functioning in conceptual, social, and practical domains.

Regrettably, many authors focus exclusively on intellectual functioning and IQ, classifying patients as having intellectual disability based on intelligence tests alone.^1,2 Adaptive capabilities are insufficiently taken into consideration; there is an urgent need to supplement IQ testing with neuropsychological testing of a patient’s cognitive and adaptive functioning.

Landmark case
In 1995, Sandra Jensen, age 34, with trisomy 21 (Down syndrome) was denied a heart and lung transplant at 2 prominent academic institutions. The denial created a national debate; Jensen’s advocates persuaded one of the hospitals to reconsider.^3,4 

In 1996, Jensen received the transplant, but she died 18 months later from complications of immunosuppressive therapy. Her surgery was a landmark event; previously, no patient with trisomy 21 or intellectual disability had undergone organ transplantation.

Although attitudes and practices have changed in the past 2 decades, intellectual disability is still considered a relative contraindication to certain organ transplants.⁵

Why is intellectual disability still a contraindication?
Allocation of transplant organs is based primarily on the ethical principle of utilitarianism: ie, a morally good action is one that helps the greatest number of people. “Benefit” might take the form of the number of lives saved or the number of years added to a patient’s life.

There is little consensus on the definition of quality of life, with its debatable ideological standpoint that stands, at times, in contrast to distributive justice. Studies have shown that the long-term outcome for patients with intellectual disability who received a kidney transplant is comparable to the outcome after renal transplant for patients who are not intellectually disabled. In other studies, patients with intellectual disability and their caregivers report improvement in quality of life after transplant.

The goal of successful transplantation is improvement in quality of life and an increase in longevity. Compliance with all aspects of post-transplant treatment is essential—which is why intellectual disability remains a relative contraindication to heart transplantation in the guidelines of the International Society for Heart and Lung Transplantation. The society’s position is based on a theoretical rationale: ie, “concerns about compliance.”

Only 7 cases of successful long-term outcome after cardiac transplantation have been reported in patients with intellectual disability, and these were marked by the presence of the social and cognitive support necessary for post-transplant compliance with treatment.⁵ One of these 7 patients had a lengthy hospitalization 4 years after transplantation because of poor adherence to his medication regimen, following the functional decline of his primary caregiver.

Two-pronged evaluation is needed. Most patients undergoing organ transplantation receive a psychosocial assessment that varies from institution to institution. Intellectual disability can add complexity to the task of assessing candidacy for transplantation, however. In these patients, the availability and adequacy of caregivers is as important a part of decision-making as assessment of the patients themselves—yet studies of the assessment of caregivers are limited. The patient’s caregivers should be present during evaluation so that their knowledge, ability, and willingness to take on post-transplant responsibilities can be assessed. More research is needed on long-term outcomes of successful transplantation in patients with intellectual disability.

CASE CONTINUED Placement on hold
The transplant committee decides to postpone placing Mr. B on the transplant waiting list. Consensus is to revisit the question of placing him on the list at a later date.

What led to this decision?
The committee had several concerns about approving Mr. B for a transplant:

• His history of pulling out the catheter meant that he would require closer postoperative monitoring, because he would likely have drains and a urinary catheter inserted.
• Maintaining adequate oral hydration with a new kidney could be a challenge because Mr. B would not be able to comprehend how dehydration can destroy a new kidney.
• His parents believed that, after transplant, Mr. B would not be dependent on them; they failed to understand that he requires lifelong supervision to ensure compliance with immunosuppressive medications and return for follow-up.

The committee’s decision was aided by the rationale that dialysis is readily available and is a sustainable alternative to transplantation.

Mr. B’s case raises an ethical question
We speculate what the team’s decision about transplantation would have been if Mr. B (1) had a living donor or (2) was being considered for a heart, lung, or liver transplant—for which there is no analogous procedure to dialysis to sustain the patient.

CASE REPORT Evaluation for renal transplant

Mr. B, age 21, who has a diagnosis of autism spectrum disorder and an IQ comparable to that of a 4-year-old, is referred for evaluation of his candidacy for renal transplant.

A few months earlier, Mr. B pulled out his temporary dialysis catheter. Now, he receives hemodialysis through an arteriovenous fistula in the arm, but requires constant supervision during dialysis.

At evaluation, Mr. B is accompanied by his parents and his older sister, who have been providing day-to-day care for him. They appear fully committed to his well-being.

Mr. B does not have a living donor.

Needed: Assessment of adaptive functioning
DSM-5 defines intellectual disability as a disorder with onset during the developmental period. It includes deficits of intellectual and adaptive functioning in conceptual, social, and practical domains.

Regrettably, many authors focus exclusively on intellectual functioning and IQ, classifying patients as having intellectual disability based on intelligence tests alone.^1,2 Adaptive capabilities are insufficiently taken into consideration; there is an urgent need to supplement IQ testing with neuropsychological testing of a patient’s cognitive and adaptive functioning.

Landmark case
In 1995, Sandra Jensen, age 34, with trisomy 21 (Down syndrome) was denied a heart and lung transplant at 2 prominent academic institutions. The denial created a national debate; Jensen’s advocates persuaded one of the hospitals to reconsider.^3,4 

In 1996, Jensen received the transplant, but she died 18 months later from complications of immunosuppressive therapy. Her surgery was a landmark event; previously, no patient with trisomy 21 or intellectual disability had undergone organ transplantation.

Although attitudes and practices have changed in the past 2 decades, intellectual disability is still considered a relative contraindication to certain organ transplants.⁵

Why is intellectual disability still a contraindication?
Allocation of transplant organs is based primarily on the ethical principle of utilitarianism: ie, a morally good action is one that helps the greatest number of people. “Benefit” might take the form of the number of lives saved or the number of years added to a patient’s life.

There is little consensus on the definition of quality of life, with its debatable ideological standpoint that stands, at times, in contrast to distributive justice. Studies have shown that the long-term outcome for patients with intellectual disability who received a kidney transplant is comparable to the outcome after renal transplant for patients who are not intellectually disabled. In other studies, patients with intellectual disability and their caregivers report improvement in quality of life after transplant.

The goal of successful transplantation is improvement in quality of life and an increase in longevity. Compliance with all aspects of post-transplant treatment is essential—which is why intellectual disability remains a relative contraindication to heart transplantation in the guidelines of the International Society for Heart and Lung Transplantation. The society’s position is based on a theoretical rationale: ie, “concerns about compliance.”

Only 7 cases of successful long-term outcome after cardiac transplantation have been reported in patients with intellectual disability, and these were marked by the presence of the social and cognitive support necessary for post-transplant compliance with treatment.⁵ One of these 7 patients had a lengthy hospitalization 4 years after transplantation because of poor adherence to his medication regimen, following the functional decline of his primary caregiver.

Two-pronged evaluation is needed. Most patients undergoing organ transplantation receive a psychosocial assessment that varies from institution to institution. Intellectual disability can add complexity to the task of assessing candidacy for transplantation, however. In these patients, the availability and adequacy of caregivers is as important a part of decision-making as assessment of the patients themselves—yet studies of the assessment of caregivers are limited. The patient’s caregivers should be present during evaluation so that their knowledge, ability, and willingness to take on post-transplant responsibilities can be assessed. More research is needed on long-term outcomes of successful transplantation in patients with intellectual disability.

CASE CONTINUED Placement on hold
The transplant committee decides to postpone placing Mr. B on the transplant waiting list. Consensus is to revisit the question of placing him on the list at a later date.

What led to this decision?
The committee had several concerns about approving Mr. B for a transplant:

• His history of pulling out the catheter meant that he would require closer postoperative monitoring, because he would likely have drains and a urinary catheter inserted.
• Maintaining adequate oral hydration with a new kidney could be a challenge because Mr. B would not be able to comprehend how dehydration can destroy a new kidney.
• His parents believed that, after transplant, Mr. B would not be dependent on them; they failed to understand that he requires lifelong supervision to ensure compliance with immunosuppressive medications and return for follow-up.

The committee’s decision was aided by the rationale that dialysis is readily available and is a sustainable alternative to transplantation.

Mr. B’s case raises an ethical question
We speculate what the team’s decision about transplantation would have been if Mr. B (1) had a living donor or (2) was being considered for a heart, lung, or liver transplant—for which there is no analogous procedure to dialysis to sustain the patient.

CASE REPORT Evaluation for renal transplant

Mr. B, age 21, who has a diagnosis of autism spectrum disorder and an IQ comparable to that of a 4-year-old, is referred for evaluation of his candidacy for renal transplant.

A few months earlier, Mr. B pulled out his temporary dialysis catheter. Now, he receives hemodialysis through an arteriovenous fistula in the arm, but requires constant supervision during dialysis.

At evaluation, Mr. B is accompanied by his parents and his older sister, who have been providing day-to-day care for him. They appear fully committed to his well-being.

Mr. B does not have a living donor.

Needed: Assessment of adaptive functioning
DSM-5 defines intellectual disability as a disorder with onset during the developmental period. It includes deficits of intellectual and adaptive functioning in conceptual, social, and practical domains.

Regrettably, many authors focus exclusively on intellectual functioning and IQ, classifying patients as having intellectual disability based on intelligence tests alone.^1,2 Adaptive capabilities are insufficiently taken into consideration; there is an urgent need to supplement IQ testing with neuropsychological testing of a patient’s cognitive and adaptive functioning.

Landmark case
In 1995, Sandra Jensen, age 34, with trisomy 21 (Down syndrome) was denied a heart and lung transplant at 2 prominent academic institutions. The denial created a national debate; Jensen’s advocates persuaded one of the hospitals to reconsider.^3,4 

In 1996, Jensen received the transplant, but she died 18 months later from complications of immunosuppressive therapy. Her surgery was a landmark event; previously, no patient with trisomy 21 or intellectual disability had undergone organ transplantation.

Although attitudes and practices have changed in the past 2 decades, intellectual disability is still considered a relative contraindication to certain organ transplants.⁵

Why is intellectual disability still a contraindication?
Allocation of transplant organs is based primarily on the ethical principle of utilitarianism: ie, a morally good action is one that helps the greatest number of people. “Benefit” might take the form of the number of lives saved or the number of years added to a patient’s life.

There is little consensus on the definition of quality of life, with its debatable ideological standpoint that stands, at times, in contrast to distributive justice. Studies have shown that the long-term outcome for patients with intellectual disability who received a kidney transplant is comparable to the outcome after renal transplant for patients who are not intellectually disabled. In other studies, patients with intellectual disability and their caregivers report improvement in quality of life after transplant.

The goal of successful transplantation is improvement in quality of life and an increase in longevity. Compliance with all aspects of post-transplant treatment is essential—which is why intellectual disability remains a relative contraindication to heart transplantation in the guidelines of the International Society for Heart and Lung Transplantation. The society’s position is based on a theoretical rationale: ie, “concerns about compliance.”

Only 7 cases of successful long-term outcome after cardiac transplantation have been reported in patients with intellectual disability, and these were marked by the presence of the social and cognitive support necessary for post-transplant compliance with treatment.⁵ One of these 7 patients had a lengthy hospitalization 4 years after transplantation because of poor adherence to his medication regimen, following the functional decline of his primary caregiver.

Two-pronged evaluation is needed. Most patients undergoing organ transplantation receive a psychosocial assessment that varies from institution to institution. Intellectual disability can add complexity to the task of assessing candidacy for transplantation, however. In these patients, the availability and adequacy of caregivers is as important a part of decision-making as assessment of the patients themselves—yet studies of the assessment of caregivers are limited. The patient’s caregivers should be present during evaluation so that their knowledge, ability, and willingness to take on post-transplant responsibilities can be assessed. More research is needed on long-term outcomes of successful transplantation in patients with intellectual disability.

CASE CONTINUED Placement on hold
The transplant committee decides to postpone placing Mr. B on the transplant waiting list. Consensus is to revisit the question of placing him on the list at a later date.

What led to this decision?
The committee had several concerns about approving Mr. B for a transplant:

• His history of pulling out the catheter meant that he would require closer postoperative monitoring, because he would likely have drains and a urinary catheter inserted.
• Maintaining adequate oral hydration with a new kidney could be a challenge because Mr. B would not be able to comprehend how dehydration can destroy a new kidney.
• His parents believed that, after transplant, Mr. B would not be dependent on them; they failed to understand that he requires lifelong supervision to ensure compliance with immunosuppressive medications and return for follow-up.

The committee’s decision was aided by the rationale that dialysis is readily available and is a sustainable alternative to transplantation.

Mr. B’s case raises an ethical question
We speculate what the team’s decision about transplantation would have been if Mr. B (1) had a living donor or (2) was being considered for a heart, lung, or liver transplant—for which there is no analogous procedure to dialysis to sustain the patient.

As I approach my twentieth year as Residency Program Coordinator in the Department of Psychiatry at Saint Louis University School of Medicine, I’ve been reflecting on the many changes that have occurred: within our residency program; in the requirements that all residency programs must meet to continue as an Accreditation Council for Graduate Medical Education (ACGME)-accredited program; and in the overall scope of psychiatry residency training.

What has changed
During my time as Residency Program Coordinator, I have assisted 5 program directors and 3 associate program directors with day-to-day details of residency training. Our residency program has had couples, and a father and son; some residents even married each other while still in training.

The Electronic Residency Application System was not available until 2001; before that, applicants interested in being invited for an interview with a psychiatry residency program had to mail in their applications for review. This was a time-consuming, tedious process. In addition, residency programs today are required to use the American Board of Psychiatry and Neurology (ABPN) PreCERT credentialing program to verify training—instead of (as in the past) simply submitting a letter to ABPN that detailed the rotations and clinical skills examinations completed.

Residency programs have gone from evaluating residents by using the 6 competencies to the Milestones requirement from ACGME, which is the newest system of measuring residents’ competencies. Every month, the program faculty meets to discuss the progress of 1 of the classes of residents and the residents who are completing an individual self-assessment. Milestone scores for each resident are then reported to ACGME.

At one time, a resident’s files could be stored in a 2-inch binder; now, we need a 4-inch binder to accommodate required documentation! I am relieved—as, I am sure, many other residency program coordinators are—that residency programs are no longer required to prepare a Program Information Form but, instead, perform a self-study and, every 10 years, have a site visit. Last, every academic year, the Residency Program Coordinator is required to enter the incoming residents’ information into the graduate medical education track, ACGME, and PreCERT Web site systems.

Rewards of my position
As Residency Program Coordinator, I’ve had the rewarding experience of meeting physicians from all over the world without having to travel to other countries. Because I have a 3- or 4-year relationship with residents, I serve them in various roles: mentor, mother, confidante, motivator, and friend. As much as the job is rewarding, being the Residency Program Coordinator can, on some days, be overwhelming, particularly because I need to think “out of the box” to streamline decisions and thus avoid conflicts with program rotations and didactic schedules.

As I approach my twentieth year as Residency Program Coordinator in the Department of Psychiatry at Saint Louis University School of Medicine, I’ve been reflecting on the many changes that have occurred: within our residency program; in the requirements that all residency programs must meet to continue as an Accreditation Council for Graduate Medical Education (ACGME)-accredited program; and in the overall scope of psychiatry residency training.

What has changed
During my time as Residency Program Coordinator, I have assisted 5 program directors and 3 associate program directors with day-to-day details of residency training. Our residency program has had couples, and a father and son; some residents even married each other while still in training.

The Electronic Residency Application System was not available until 2001; before that, applicants interested in being invited for an interview with a psychiatry residency program had to mail in their applications for review. This was a time-consuming, tedious process. In addition, residency programs today are required to use the American Board of Psychiatry and Neurology (ABPN) PreCERT credentialing program to verify training—instead of (as in the past) simply submitting a letter to ABPN that detailed the rotations and clinical skills examinations completed.

Residency programs have gone from evaluating residents by using the 6 competencies to the Milestones requirement from ACGME, which is the newest system of measuring residents’ competencies. Every month, the program faculty meets to discuss the progress of 1 of the classes of residents and the residents who are completing an individual self-assessment. Milestone scores for each resident are then reported to ACGME.

At one time, a resident’s files could be stored in a 2-inch binder; now, we need a 4-inch binder to accommodate required documentation! I am relieved—as, I am sure, many other residency program coordinators are—that residency programs are no longer required to prepare a Program Information Form but, instead, perform a self-study and, every 10 years, have a site visit. Last, every academic year, the Residency Program Coordinator is required to enter the incoming residents’ information into the graduate medical education track, ACGME, and PreCERT Web site systems.

Rewards of my position
As Residency Program Coordinator, I’ve had the rewarding experience of meeting physicians from all over the world without having to travel to other countries. Because I have a 3- or 4-year relationship with residents, I serve them in various roles: mentor, mother, confidante, motivator, and friend. As much as the job is rewarding, being the Residency Program Coordinator can, on some days, be overwhelming, particularly because I need to think “out of the box” to streamline decisions and thus avoid conflicts with program rotations and didactic schedules.

As I approach my twentieth year as Residency Program Coordinator in the Department of Psychiatry at Saint Louis University School of Medicine, I’ve been reflecting on the many changes that have occurred: within our residency program; in the requirements that all residency programs must meet to continue as an Accreditation Council for Graduate Medical Education (ACGME)-accredited program; and in the overall scope of psychiatry residency training.

What has changed
During my time as Residency Program Coordinator, I have assisted 5 program directors and 3 associate program directors with day-to-day details of residency training. Our residency program has had couples, and a father and son; some residents even married each other while still in training.

The Electronic Residency Application System was not available until 2001; before that, applicants interested in being invited for an interview with a psychiatry residency program had to mail in their applications for review. This was a time-consuming, tedious process. In addition, residency programs today are required to use the American Board of Psychiatry and Neurology (ABPN) PreCERT credentialing program to verify training—instead of (as in the past) simply submitting a letter to ABPN that detailed the rotations and clinical skills examinations completed.

Residency programs have gone from evaluating residents by using the 6 competencies to the Milestones requirement from ACGME, which is the newest system of measuring residents’ competencies. Every month, the program faculty meets to discuss the progress of 1 of the classes of residents and the residents who are completing an individual self-assessment. Milestone scores for each resident are then reported to ACGME.

At one time, a resident’s files could be stored in a 2-inch binder; now, we need a 4-inch binder to accommodate required documentation! I am relieved—as, I am sure, many other residency program coordinators are—that residency programs are no longer required to prepare a Program Information Form but, instead, perform a self-study and, every 10 years, have a site visit. Last, every academic year, the Residency Program Coordinator is required to enter the incoming residents’ information into the graduate medical education track, ACGME, and PreCERT Web site systems.

Rewards of my position
As Residency Program Coordinator, I’ve had the rewarding experience of meeting physicians from all over the world without having to travel to other countries. Because I have a 3- or 4-year relationship with residents, I serve them in various roles: mentor, mother, confidante, motivator, and friend. As much as the job is rewarding, being the Residency Program Coordinator can, on some days, be overwhelming, particularly because I need to think “out of the box” to streamline decisions and thus avoid conflicts with program rotations and didactic schedules.

The prevalence of obesity and obesity-related conditions in the United States is increasing. Many weight-loss prod­ucts and dietary supplements are used in an attempt to combat this epidemic, but little evi­dence exists of their efficacy and safety.

We present a case report of a middle-age woman who developed severe psychotic symptoms while taking phentermine hydro­chloride (HCl), a psychostimulant similar to amphetamine that is used as a weight-loss agent and for recreational purposes. Phentermine has been associated with mood and psychotic symptoms and has a tendency to cause psychological dependence and tolerance.

To investigate the risks and potential effects of using this drug, we searched OVID and PubMed databases using the search string “phentermine + psychosis.” We conclude that there is a need for awareness about early detection and treatment of reversible psy­chotic and mood symptoms caused by what might appear to be harmless weight-loss and energy pills.

Obesity epidemic, wide-ranging weight-loss effortsThere has been a dramatic increase in obesity in the United States in the past 20 years: More than one-third of adults and approximately 17% of children and adolescents are obese. Obesity-related conditions, such as heart dis­ease, stroke, and type 2 diabetes mellitus, are leading causes of preventable death.¹ Weight monitoring, a healthy lifestyle, surgical inter­vention, traditional herbs, and diet-pill sup­plements are some of the modalities used to address this epidemic.

Most so-called supplements for weight loss are exempt from FDA regulation. They do not undergo rigorous testing for safety. Furthermore, many contain controlled sub­stances; some supplements are anti-seizure medications or other prescription drugs; and some are drugs not approved in the United States.² Since the 1930s, such drugs as dini­trophenol, ephedrine, amphetamine, fenflu­ramine, and phentermine have flooded the market with the promise of quick weight loss.^3,4

Phentermine, a contraction of “phenyltertiary-butylamine,” and its various types (Table) is a psychostimu­lant of the phenethylamine class, with a pharmacologic profile similar to that of amphetamine. It is known to yield false-positive immunoassay screening results for amphetamines.
 

Speech is pressured, fast, and difficult to comprehend at times; affect is labile and irri­table. Ms. B denies suicidal ideation and is oriented to time, place, and person.

A urine drug screen is positive for amphetamine.

Pre-admission medications include alpra­zolam, 1 mg as needed, and zolpidem, 10 mg at bedtime, prescribed by Ms. B’s primary care physician for anxiety and insomnia. She discontinued these medications 3 weeks ago because of increased drowsiness at work. She denies other substance use and is unable to account for the positive urine drug screen.

Her medical history, physical examination, and a CT scan of the head are unremarkable. The components of a comprehensive meta­bolic panel and complete blood count are within normal limits.

After admission, in-depth assessment reveals that Ms. B has been taking phen­termine, 37.5 mg (under the brand name Adipex-P), once daily since age 16 for weight loss. She recently discontinued the drug, abruptly, for 1 month, then resumed taking it at an unspecified higher dosage 1 week before she came to the emergency room, for what she said was recreational use and to meet the demands of her job, which required shift work and long hours.

Over the next few days in the hospital, Ms. B’s symptoms resolve as the drug is eliminated from her body. Speech becomes comprehensible and sleep improves. Affective distress diminishes considerably after admission; slight mood lability per­sists. She no longer reports perceptual dis­turbances or distress secondary to intrusive thoughts.

Ms. B is discharged 1 week after admis­sion, with instructions to follow up at a dual-diagnosis outpatient program.
Pharmacologic profilePhentermine acts through sympathomi­metic pathways by increasing brain nor­adrenaline and dopamine. The drug has no effect on serotonin.^4,5 Phentermine can lead to elevated blood pressure and heart rate, palpitations, restlessness, and insomnia, and can suppress appetite. Increased sympatho­mimetic activity has been implicated in the ability of phentermine to induce psychotic symptoms.

The literature. Our PubMed search of “phentermine + psychosis” produced 13 results, including 6 case reports of phen­termine use. Five citations were more than 4 decades old^5-12; only 1 could be considered recent (2011).¹³

Patients in these reports developed psy­chotic or manic features after chronic or acute phentermine use, mainly for weight reduction. The most recent article¹³ men­tioned 4 patients who were abusing diet pills recreationally (including “for lethargy”). As with Ms. B, in all 4 of those patients, phen­termine precipitated the primary pathol­ogy (mania in bipolar disorder; depression in postpartum depression and substance abuse) or revealed underlying illness.
Changing landscape of use and abuseThere has been a trend observed in the pattern of diet pill use: Initially marketed as an appetite suppressant, these pills are now being abused across ethnic, racial, and socioeconomic groups, by males and females.¹⁴ There is also a scarcity of useful guidance for clinicians.

Not only are diet pills used by people with an eating disorder; their recreational use is an emerging problem. If reports^12,13 continue to reveal that phentermine is a substance of abuse and has catastrophic effects on the user’s psyche, the need for stronger warnings and guidelines might be warranted to allow consumers to make an informed choice about using the drug.
Call for awarenessThe case we presented here exemplifies the importance of tighter regulation of both over-the-counter and prescription stimu­lant analogs. There is a need for awareness among practitioners about early detection and treatment of reversible psychotic and mood symptoms secondary to what might be promoted as, or appear to be, “harmless” weight loss and energy pills.
 

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

This unfunded study was presented as a case report poster at the Annual Meeting of the Academy of Psychosomatic Medicine, November 2013, Tucson, Arizona, and at the Colloquium of Scholars of the Philadelphia Psychiatric Society, March 2014, Philadelphia, Pennsylvania.
 

Drug Brand Names
Alprazolam • Xanax
Fenfluramine • Pondimin
Phentermine HCl • Adipex-P, Fen-Phen, Qsymia, Suprenza
Topiramate • Topamax, Trokendi XR                
Zolpidem • Ambien

The prevalence of obesity and obesity-related conditions in the United States is increasing. Many weight-loss prod­ucts and dietary supplements are used in an attempt to combat this epidemic, but little evi­dence exists of their efficacy and safety.

We present a case report of a middle-age woman who developed severe psychotic symptoms while taking phentermine hydro­chloride (HCl), a psychostimulant similar to amphetamine that is used as a weight-loss agent and for recreational purposes. Phentermine has been associated with mood and psychotic symptoms and has a tendency to cause psychological dependence and tolerance.

To investigate the risks and potential effects of using this drug, we searched OVID and PubMed databases using the search string “phentermine + psychosis.” We conclude that there is a need for awareness about early detection and treatment of reversible psy­chotic and mood symptoms caused by what might appear to be harmless weight-loss and energy pills.

Obesity epidemic, wide-ranging weight-loss effortsThere has been a dramatic increase in obesity in the United States in the past 20 years: More than one-third of adults and approximately 17% of children and adolescents are obese. Obesity-related conditions, such as heart dis­ease, stroke, and type 2 diabetes mellitus, are leading causes of preventable death.¹ Weight monitoring, a healthy lifestyle, surgical inter­vention, traditional herbs, and diet-pill sup­plements are some of the modalities used to address this epidemic.

Most so-called supplements for weight loss are exempt from FDA regulation. They do not undergo rigorous testing for safety. Furthermore, many contain controlled sub­stances; some supplements are anti-seizure medications or other prescription drugs; and some are drugs not approved in the United States.² Since the 1930s, such drugs as dini­trophenol, ephedrine, amphetamine, fenflu­ramine, and phentermine have flooded the market with the promise of quick weight loss.^3,4

Phentermine, a contraction of “phenyltertiary-butylamine,” and its various types (Table) is a psychostimu­lant of the phenethylamine class, with a pharmacologic profile similar to that of amphetamine. It is known to yield false-positive immunoassay screening results for amphetamines.
 

Speech is pressured, fast, and difficult to comprehend at times; affect is labile and irri­table. Ms. B denies suicidal ideation and is oriented to time, place, and person.

A urine drug screen is positive for amphetamine.

Pre-admission medications include alpra­zolam, 1 mg as needed, and zolpidem, 10 mg at bedtime, prescribed by Ms. B’s primary care physician for anxiety and insomnia. She discontinued these medications 3 weeks ago because of increased drowsiness at work. She denies other substance use and is unable to account for the positive urine drug screen.

Her medical history, physical examination, and a CT scan of the head are unremarkable. The components of a comprehensive meta­bolic panel and complete blood count are within normal limits.

After admission, in-depth assessment reveals that Ms. B has been taking phen­termine, 37.5 mg (under the brand name Adipex-P), once daily since age 16 for weight loss. She recently discontinued the drug, abruptly, for 1 month, then resumed taking it at an unspecified higher dosage 1 week before she came to the emergency room, for what she said was recreational use and to meet the demands of her job, which required shift work and long hours.

Over the next few days in the hospital, Ms. B’s symptoms resolve as the drug is eliminated from her body. Speech becomes comprehensible and sleep improves. Affective distress diminishes considerably after admission; slight mood lability per­sists. She no longer reports perceptual dis­turbances or distress secondary to intrusive thoughts.

Ms. B is discharged 1 week after admis­sion, with instructions to follow up at a dual-diagnosis outpatient program.
Pharmacologic profilePhentermine acts through sympathomi­metic pathways by increasing brain nor­adrenaline and dopamine. The drug has no effect on serotonin.^4,5 Phentermine can lead to elevated blood pressure and heart rate, palpitations, restlessness, and insomnia, and can suppress appetite. Increased sympatho­mimetic activity has been implicated in the ability of phentermine to induce psychotic symptoms.

The literature. Our PubMed search of “phentermine + psychosis” produced 13 results, including 6 case reports of phen­termine use. Five citations were more than 4 decades old^5-12; only 1 could be considered recent (2011).¹³

Patients in these reports developed psy­chotic or manic features after chronic or acute phentermine use, mainly for weight reduction. The most recent article¹³ men­tioned 4 patients who were abusing diet pills recreationally (including “for lethargy”). As with Ms. B, in all 4 of those patients, phen­termine precipitated the primary pathol­ogy (mania in bipolar disorder; depression in postpartum depression and substance abuse) or revealed underlying illness.
Changing landscape of use and abuseThere has been a trend observed in the pattern of diet pill use: Initially marketed as an appetite suppressant, these pills are now being abused across ethnic, racial, and socioeconomic groups, by males and females.¹⁴ There is also a scarcity of useful guidance for clinicians.

Not only are diet pills used by people with an eating disorder; their recreational use is an emerging problem. If reports^12,13 continue to reveal that phentermine is a substance of abuse and has catastrophic effects on the user’s psyche, the need for stronger warnings and guidelines might be warranted to allow consumers to make an informed choice about using the drug.
Call for awarenessThe case we presented here exemplifies the importance of tighter regulation of both over-the-counter and prescription stimu­lant analogs. There is a need for awareness among practitioners about early detection and treatment of reversible psychotic and mood symptoms secondary to what might be promoted as, or appear to be, “harmless” weight loss and energy pills.
 

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

This unfunded study was presented as a case report poster at the Annual Meeting of the Academy of Psychosomatic Medicine, November 2013, Tucson, Arizona, and at the Colloquium of Scholars of the Philadelphia Psychiatric Society, March 2014, Philadelphia, Pennsylvania.
 

Drug Brand Names
Alprazolam • Xanax
Fenfluramine • Pondimin
Phentermine HCl • Adipex-P, Fen-Phen, Qsymia, Suprenza
Topiramate • Topamax, Trokendi XR                
Zolpidem • Ambien

The prevalence of obesity and obesity-related conditions in the United States is increasing. Many weight-loss prod­ucts and dietary supplements are used in an attempt to combat this epidemic, but little evi­dence exists of their efficacy and safety.

We present a case report of a middle-age woman who developed severe psychotic symptoms while taking phentermine hydro­chloride (HCl), a psychostimulant similar to amphetamine that is used as a weight-loss agent and for recreational purposes. Phentermine has been associated with mood and psychotic symptoms and has a tendency to cause psychological dependence and tolerance.

To investigate the risks and potential effects of using this drug, we searched OVID and PubMed databases using the search string “phentermine + psychosis.” We conclude that there is a need for awareness about early detection and treatment of reversible psy­chotic and mood symptoms caused by what might appear to be harmless weight-loss and energy pills.

Obesity epidemic, wide-ranging weight-loss effortsThere has been a dramatic increase in obesity in the United States in the past 20 years: More than one-third of adults and approximately 17% of children and adolescents are obese. Obesity-related conditions, such as heart dis­ease, stroke, and type 2 diabetes mellitus, are leading causes of preventable death.¹ Weight monitoring, a healthy lifestyle, surgical inter­vention, traditional herbs, and diet-pill sup­plements are some of the modalities used to address this epidemic.

Most so-called supplements for weight loss are exempt from FDA regulation. They do not undergo rigorous testing for safety. Furthermore, many contain controlled sub­stances; some supplements are anti-seizure medications or other prescription drugs; and some are drugs not approved in the United States.² Since the 1930s, such drugs as dini­trophenol, ephedrine, amphetamine, fenflu­ramine, and phentermine have flooded the market with the promise of quick weight loss.^3,4

Phentermine, a contraction of “phenyltertiary-butylamine,” and its various types (Table) is a psychostimu­lant of the phenethylamine class, with a pharmacologic profile similar to that of amphetamine. It is known to yield false-positive immunoassay screening results for amphetamines.
 

Speech is pressured, fast, and difficult to comprehend at times; affect is labile and irri­table. Ms. B denies suicidal ideation and is oriented to time, place, and person.

A urine drug screen is positive for amphetamine.

Pre-admission medications include alpra­zolam, 1 mg as needed, and zolpidem, 10 mg at bedtime, prescribed by Ms. B’s primary care physician for anxiety and insomnia. She discontinued these medications 3 weeks ago because of increased drowsiness at work. She denies other substance use and is unable to account for the positive urine drug screen.

Her medical history, physical examination, and a CT scan of the head are unremarkable. The components of a comprehensive meta­bolic panel and complete blood count are within normal limits.

After admission, in-depth assessment reveals that Ms. B has been taking phen­termine, 37.5 mg (under the brand name Adipex-P), once daily since age 16 for weight loss. She recently discontinued the drug, abruptly, for 1 month, then resumed taking it at an unspecified higher dosage 1 week before she came to the emergency room, for what she said was recreational use and to meet the demands of her job, which required shift work and long hours.

Over the next few days in the hospital, Ms. B’s symptoms resolve as the drug is eliminated from her body. Speech becomes comprehensible and sleep improves. Affective distress diminishes considerably after admission; slight mood lability per­sists. She no longer reports perceptual dis­turbances or distress secondary to intrusive thoughts.

Ms. B is discharged 1 week after admis­sion, with instructions to follow up at a dual-diagnosis outpatient program.
Pharmacologic profilePhentermine acts through sympathomi­metic pathways by increasing brain nor­adrenaline and dopamine. The drug has no effect on serotonin.^4,5 Phentermine can lead to elevated blood pressure and heart rate, palpitations, restlessness, and insomnia, and can suppress appetite. Increased sympatho­mimetic activity has been implicated in the ability of phentermine to induce psychotic symptoms.

The literature. Our PubMed search of “phentermine + psychosis” produced 13 results, including 6 case reports of phen­termine use. Five citations were more than 4 decades old^5-12; only 1 could be considered recent (2011).¹³

Patients in these reports developed psy­chotic or manic features after chronic or acute phentermine use, mainly for weight reduction. The most recent article¹³ men­tioned 4 patients who were abusing diet pills recreationally (including “for lethargy”). As with Ms. B, in all 4 of those patients, phen­termine precipitated the primary pathol­ogy (mania in bipolar disorder; depression in postpartum depression and substance abuse) or revealed underlying illness.
Changing landscape of use and abuseThere has been a trend observed in the pattern of diet pill use: Initially marketed as an appetite suppressant, these pills are now being abused across ethnic, racial, and socioeconomic groups, by males and females.¹⁴ There is also a scarcity of useful guidance for clinicians.

Not only are diet pills used by people with an eating disorder; their recreational use is an emerging problem. If reports^12,13 continue to reveal that phentermine is a substance of abuse and has catastrophic effects on the user’s psyche, the need for stronger warnings and guidelines might be warranted to allow consumers to make an informed choice about using the drug.
Call for awarenessThe case we presented here exemplifies the importance of tighter regulation of both over-the-counter and prescription stimu­lant analogs. There is a need for awareness among practitioners about early detection and treatment of reversible psychotic and mood symptoms secondary to what might be promoted as, or appear to be, “harmless” weight loss and energy pills.
 

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

This unfunded study was presented as a case report poster at the Annual Meeting of the Academy of Psychosomatic Medicine, November 2013, Tucson, Arizona, and at the Colloquium of Scholars of the Philadelphia Psychiatric Society, March 2014, Philadelphia, Pennsylvania.
 

Drug Brand Names
Alprazolam • Xanax
Fenfluramine • Pondimin
Phentermine HCl • Adipex-P, Fen-Phen, Qsymia, Suprenza
Topiramate • Topamax, Trokendi XR                
Zolpidem • Ambien

Perhaps more than any other medical specialty, psychiatry enjoys a longstanding and, at times, complicated relationship with cinema. Recent award-winning films, such as Still Alice, Silver Linings Playbook, and Birdman: Or (The Unexpected Virtue of Ignorance) continue traditions rooted in One Flew Over the Cuckoo’s Nest, Martha Marcy May Marlene, Spellbound, and dozens of other films. Through these films, psychiatry is afforded exposure unavailable to most medical specialties. This exposure has proven to be a double-edged sword, however.

Exposure vs accurate portrayal
Relative benefits and disadvantages of psychiatry’s position in film and popular media are difficult to calculate. A film such as Still Alice can provide a vivid, concrete personal narrative of a patient with Alzheimer’s disease, equipping millions of viewers with knowledge that might otherwise remain esoteric and inaccessible. Martha Marcy May Marlene offers a similar stage for posttraumatic stress disorder (PTSD), as does Spellbound for dissociative amnesia.

Such exposure comes at a cost, inevitably, because information about psychiatry is incorporated into a dramatic storyline assembled by filmmakers who are not medical professionals and who are bound by conflicting pressures. At times, those pressures outweigh the desire to accurately portray psychiatric illness.

‘Magical realism’
Two of last year’s celebrated films, Birdman and Still Alice, have continued the longstanding tradition of portraying mental illness in film. Medicine often is touted as art and science; film likewise sits at this intersection. However, filmmakers are artists, primarily, and the nature of storytelling is to emphasize art over scientific accuracy.

The main character in Birdman, for example, manifests psychosis, but many of his presenting signs and symptoms are incongruent with any diagnosable form of psychosis. To tell its story, the film employs magical realism, a celebrated literary and film technique. Although magical realism might detract from the accuracy of the condition portrayed, it adds cinematic appeal to the film, likely creates more entertainment value, and, in turn, garners appreciation from a broader audience.

Expansion of medical information, accurate and otherwise
As in the 1970’s, we are, today, in the midst of rapidly evolving societal norms. One of the most rapid changes is in how the public acquires information. We are in the midst of the “Googlification” of medical knowledge and the expansion of online medical resources. These resources can, simultaneously, inform and mislead the public.

Popular films behave in much the same way. There is no motion picture-guild requirement that mentally ill characters in films such as Birdman meet any set of psychiatric criteria, from DSM-5 or elsewhere. Similarly, the fact that psychiatrists do not control the information in films that portray mental illness comes as no surprise.

‘One flew East, one flew West…’
The tension between engaging storytelling and medical accuracy certainly is not a new phenomenon, extending not only to representations of disease but to representations of treatment. Consider director Miloš Forman’s seminal 1975 film, One Flew Over the Cuckoo’s Nest, whose chief importance for psychiatry rests not in its individualized representations of patients but in a portrayal of the environment in which they are treated. Louise Fletcher’s Academy Award-winning portrayal of cruel Nurse Ratched has lingered in the public consciousness, remaining a prominent image for many Americans when they think of a psychiatric institution.

When Cuckoo’s Nest was released, it was considered by critics to be an “exploration of society’s enforcement of conformism” that “almost willfully overlooked the realities of mental illness”¹ so that it could vivify its protagonist’s struggle against tyrannical Nurse Ratched. The film’s primary intent might not have been to make a statement about the injustices of the time, but it has certainly had a lasting effect on the public’s perception of psychiatric illness and treatment.

Films offer an opportunity for discussion
Films on the theme of psychiatry and mental illness have long held a distinctive position in the canon of Western cinema. In this vein, films from the past year have made timely contributions to the genre. Although Still Alice and Birdman might prove to be ground-breaking in changing societal views over time, we must not expect them to do so.

Nevertheless, psychiatry ought to take advantage of popular films’ wide exposure and ability to destigmatize mental illness—rather than lament medical inaccuracies in these films.

Cinema is, first and foremost, an art. Although patients and the public might pick up misconceptions about psychosis, Alzheimer’s disease, or PTSD because popular films take artistic liberty about mental illness, psychiatrists are available to set the record straight. After all, psychiatry has long been about managing perceptions, and patient education is at the core of our specialty.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Perhaps more than any other medical specialty, psychiatry enjoys a longstanding and, at times, complicated relationship with cinema. Recent award-winning films, such as Still Alice, Silver Linings Playbook, and Birdman: Or (The Unexpected Virtue of Ignorance) continue traditions rooted in One Flew Over the Cuckoo’s Nest, Martha Marcy May Marlene, Spellbound, and dozens of other films. Through these films, psychiatry is afforded exposure unavailable to most medical specialties. This exposure has proven to be a double-edged sword, however.

Exposure vs accurate portrayal
Relative benefits and disadvantages of psychiatry’s position in film and popular media are difficult to calculate. A film such as Still Alice can provide a vivid, concrete personal narrative of a patient with Alzheimer’s disease, equipping millions of viewers with knowledge that might otherwise remain esoteric and inaccessible. Martha Marcy May Marlene offers a similar stage for posttraumatic stress disorder (PTSD), as does Spellbound for dissociative amnesia.

Such exposure comes at a cost, inevitably, because information about psychiatry is incorporated into a dramatic storyline assembled by filmmakers who are not medical professionals and who are bound by conflicting pressures. At times, those pressures outweigh the desire to accurately portray psychiatric illness.

‘Magical realism’
Two of last year’s celebrated films, Birdman and Still Alice, have continued the longstanding tradition of portraying mental illness in film. Medicine often is touted as art and science; film likewise sits at this intersection. However, filmmakers are artists, primarily, and the nature of storytelling is to emphasize art over scientific accuracy.

The main character in Birdman, for example, manifests psychosis, but many of his presenting signs and symptoms are incongruent with any diagnosable form of psychosis. To tell its story, the film employs magical realism, a celebrated literary and film technique. Although magical realism might detract from the accuracy of the condition portrayed, it adds cinematic appeal to the film, likely creates more entertainment value, and, in turn, garners appreciation from a broader audience.

Expansion of medical information, accurate and otherwise
As in the 1970’s, we are, today, in the midst of rapidly evolving societal norms. One of the most rapid changes is in how the public acquires information. We are in the midst of the “Googlification” of medical knowledge and the expansion of online medical resources. These resources can, simultaneously, inform and mislead the public.

Popular films behave in much the same way. There is no motion picture-guild requirement that mentally ill characters in films such as Birdman meet any set of psychiatric criteria, from DSM-5 or elsewhere. Similarly, the fact that psychiatrists do not control the information in films that portray mental illness comes as no surprise.

‘One flew East, one flew West…’
The tension between engaging storytelling and medical accuracy certainly is not a new phenomenon, extending not only to representations of disease but to representations of treatment. Consider director Miloš Forman’s seminal 1975 film, One Flew Over the Cuckoo’s Nest, whose chief importance for psychiatry rests not in its individualized representations of patients but in a portrayal of the environment in which they are treated. Louise Fletcher’s Academy Award-winning portrayal of cruel Nurse Ratched has lingered in the public consciousness, remaining a prominent image for many Americans when they think of a psychiatric institution.

When Cuckoo’s Nest was released, it was considered by critics to be an “exploration of society’s enforcement of conformism” that “almost willfully overlooked the realities of mental illness”¹ so that it could vivify its protagonist’s struggle against tyrannical Nurse Ratched. The film’s primary intent might not have been to make a statement about the injustices of the time, but it has certainly had a lasting effect on the public’s perception of psychiatric illness and treatment.

Films offer an opportunity for discussion
Films on the theme of psychiatry and mental illness have long held a distinctive position in the canon of Western cinema. In this vein, films from the past year have made timely contributions to the genre. Although Still Alice and Birdman might prove to be ground-breaking in changing societal views over time, we must not expect them to do so.

Nevertheless, psychiatry ought to take advantage of popular films’ wide exposure and ability to destigmatize mental illness—rather than lament medical inaccuracies in these films.

Cinema is, first and foremost, an art. Although patients and the public might pick up misconceptions about psychosis, Alzheimer’s disease, or PTSD because popular films take artistic liberty about mental illness, psychiatrists are available to set the record straight. After all, psychiatry has long been about managing perceptions, and patient education is at the core of our specialty.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Perhaps more than any other medical specialty, psychiatry enjoys a longstanding and, at times, complicated relationship with cinema. Recent award-winning films, such as Still Alice, Silver Linings Playbook, and Birdman: Or (The Unexpected Virtue of Ignorance) continue traditions rooted in One Flew Over the Cuckoo’s Nest, Martha Marcy May Marlene, Spellbound, and dozens of other films. Through these films, psychiatry is afforded exposure unavailable to most medical specialties. This exposure has proven to be a double-edged sword, however.

Exposure vs accurate portrayal
Relative benefits and disadvantages of psychiatry’s position in film and popular media are difficult to calculate. A film such as Still Alice can provide a vivid, concrete personal narrative of a patient with Alzheimer’s disease, equipping millions of viewers with knowledge that might otherwise remain esoteric and inaccessible. Martha Marcy May Marlene offers a similar stage for posttraumatic stress disorder (PTSD), as does Spellbound for dissociative amnesia.

Such exposure comes at a cost, inevitably, because information about psychiatry is incorporated into a dramatic storyline assembled by filmmakers who are not medical professionals and who are bound by conflicting pressures. At times, those pressures outweigh the desire to accurately portray psychiatric illness.

‘Magical realism’
Two of last year’s celebrated films, Birdman and Still Alice, have continued the longstanding tradition of portraying mental illness in film. Medicine often is touted as art and science; film likewise sits at this intersection. However, filmmakers are artists, primarily, and the nature of storytelling is to emphasize art over scientific accuracy.

The main character in Birdman, for example, manifests psychosis, but many of his presenting signs and symptoms are incongruent with any diagnosable form of psychosis. To tell its story, the film employs magical realism, a celebrated literary and film technique. Although magical realism might detract from the accuracy of the condition portrayed, it adds cinematic appeal to the film, likely creates more entertainment value, and, in turn, garners appreciation from a broader audience.

Expansion of medical information, accurate and otherwise
As in the 1970’s, we are, today, in the midst of rapidly evolving societal norms. One of the most rapid changes is in how the public acquires information. We are in the midst of the “Googlification” of medical knowledge and the expansion of online medical resources. These resources can, simultaneously, inform and mislead the public.

Popular films behave in much the same way. There is no motion picture-guild requirement that mentally ill characters in films such as Birdman meet any set of psychiatric criteria, from DSM-5 or elsewhere. Similarly, the fact that psychiatrists do not control the information in films that portray mental illness comes as no surprise.

‘One flew East, one flew West…’
The tension between engaging storytelling and medical accuracy certainly is not a new phenomenon, extending not only to representations of disease but to representations of treatment. Consider director Miloš Forman’s seminal 1975 film, One Flew Over the Cuckoo’s Nest, whose chief importance for psychiatry rests not in its individualized representations of patients but in a portrayal of the environment in which they are treated. Louise Fletcher’s Academy Award-winning portrayal of cruel Nurse Ratched has lingered in the public consciousness, remaining a prominent image for many Americans when they think of a psychiatric institution.

When Cuckoo’s Nest was released, it was considered by critics to be an “exploration of society’s enforcement of conformism” that “almost willfully overlooked the realities of mental illness”¹ so that it could vivify its protagonist’s struggle against tyrannical Nurse Ratched. The film’s primary intent might not have been to make a statement about the injustices of the time, but it has certainly had a lasting effect on the public’s perception of psychiatric illness and treatment.

Films offer an opportunity for discussion
Films on the theme of psychiatry and mental illness have long held a distinctive position in the canon of Western cinema. In this vein, films from the past year have made timely contributions to the genre. Although Still Alice and Birdman might prove to be ground-breaking in changing societal views over time, we must not expect them to do so.

Nevertheless, psychiatry ought to take advantage of popular films’ wide exposure and ability to destigmatize mental illness—rather than lament medical inaccuracies in these films.

Cinema is, first and foremost, an art. Although patients and the public might pick up misconceptions about psychosis, Alzheimer’s disease, or PTSD because popular films take artistic liberty about mental illness, psychiatrists are available to set the record straight. After all, psychiatry has long been about managing perceptions, and patient education is at the core of our specialty.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

The first year of residency came faster than I had expected and concluded just as quickly. At times, it felt like medical school, with different rotations, adjusting to newly formed teams, dealing with the pressures of getting the right diagnosis and treatment, managing the unrelenting speed of rounds, and trying to make a difference for the better. I must be honest – there were times when I was counting down the days for the rotation to end so that I could begin focusing and working directly in the mental health field.

Now, in my second year, the pace has improved, and the rotations resemble the work and patient population that I chose during the match process. Nonetheless, I am thankful for the time spent and the knowledge gained during my intern year, because it is only now that I understand the true value of my first-year experiences and the need to continue getting a well-rounded medical education for the benefit of my patients.

During my second year of residency, I have come across multiple instances of health disparities for people with mental illness. While working in several inpatient units, I have witnessed delayed time of visit from medical/surgical or ob.gyn. consults, shorter evaluation times from visiting consulting personnel, and postponed follow-up appointments for general medical conditions. I remember one occasion when a patient with urinary incontinence waited 3 days until internal medicine completed its consult. These experiences remind me of the conversations I had in medical school. Some of my colleagues would say, “Psychiatric patients are difficult.” Others were honest in admitting that they were scared to even enter a psychiatric inpatient unit.

Medical comorbidities common

During one 24-hour shift, I was paged to the inpatient unit. A new admission from that afternoon was complaining of “toe pain.”

The patient had been admitted for suicidal ideation and alcohol withdrawal. He reported tripping over a concrete step 2 weeks prior to admission. Under examination, he had an open laceration with purulent, foul-smelling discharge, erythema, and edema around the wound. The patient had signs of cellulitis, had a possible fracture of the phalanx, and was at risk for osteomyelitis.

He had been medically cleared at another facility prior to his admission, where he also had complained of toe pain. At that time, however, he was told, “You are not here for that,” and the extremity was not examined during the medical clearance. I ordered a referral, imaging was completed, and antibiotic treatment was started for his infection. Unfortunately, this is not an incidental or isolated case; situations similar to this one have become more frequent than we would like for those with mental illness.

Often, psychiatric patients are overlooked and undertreated. We frequently are the only physicians who evaluate the patient and help improve their quality of life. After reviewing the literature, I found countless studies concluding that patients who have a psychiatric diagnosis often have increased medical comorbidity and even increased mortality. A review and meta-analysis published earlier this year suggested that “people with mental disorders often do not receive preventive services, such as immunizations, cancer screenings, and tobacco counseling, and often receive a lower quality of care for medical conditions” (JAMA Psychiatry 2015;72:334-41). The researchers also found that “mortality was significantly higher among people with mental disorders than among the comparison population.”

Focusing on mind, body

I knew I wanted to be a psychiatrist since my early years in training. Initially, I was drawn toward psychology, in which I completed a bachelor’s degree, but my world turned around after a conversation with the father of a high school classmate. He told me: “I commend you on your decision to want to help people; however, I would like to give you food for thought. If your goal is to be of service to your patients and provide care, it would be to their benefit to address not only the mind but also the body” (which, coincidentally, is the theme of this year’s American Psychiatric Association meeting in Toronto.)

At that time, I was weighing becoming a clinician versus a physician; after all, both have instrumental roles in treatment. Yet, those words resonate now in my life for a new reason, namely, that my duty as an advocate for mental health is not only to treat psychiatric disorders but also to work toward treating general medical conditions.

I have been fortunate to cross paths with mentors who helped strengthen my commitment to well-rounded care and a multidisciplinary approach for the mentally ill. I am thankful to have worked with Dr. Jill Williams, who stressed the need to treat tobacco dependence, and Dr. Anthony Tobia, who emphasized the need to rule out substance- and medication-induced disorders prior to treatment. I have had the pleasure of working with many other attending psychiatrists who not only focused on psychiatric symptoms and diagnosis but stressed the need to address the medical care of our patients.

If I can understand my patients by learning about human behavior, conditioning, defense mechanisms, and interpersonal relationships and also focus on pathophysiology, comorbid conditions, differential diagnosis, and exacerbating medical conditions, I will be able to give them the best medical care possible.

Dr. Poulsen, a second-year psychiatry resident at the Robert Wood Johnson Medical School, Piscataway, N.J., is interested in cultural psychiatry and advocacy, and in pursuing a fellowship in child and adolescent psychiatry. After obtaining a bachelor of science degree at the University of Florida, Gainesville, he earned a medical degree at the University of Puerto Rico. He is currently serving in multiple leadership positions, including vice president of the New Jersey Psychiatric Association (NJPA) Residents Chapter and NJPA chapter advocacy coordinator. In addition, he has been selected as resident-fellow representative of the APA’s Area 3.

The first year of residency came faster than I had expected and concluded just as quickly. At times, it felt like medical school, with different rotations, adjusting to newly formed teams, dealing with the pressures of getting the right diagnosis and treatment, managing the unrelenting speed of rounds, and trying to make a difference for the better. I must be honest – there were times when I was counting down the days for the rotation to end so that I could begin focusing and working directly in the mental health field.

Now, in my second year, the pace has improved, and the rotations resemble the work and patient population that I chose during the match process. Nonetheless, I am thankful for the time spent and the knowledge gained during my intern year, because it is only now that I understand the true value of my first-year experiences and the need to continue getting a well-rounded medical education for the benefit of my patients.

During my second year of residency, I have come across multiple instances of health disparities for people with mental illness. While working in several inpatient units, I have witnessed delayed time of visit from medical/surgical or ob.gyn. consults, shorter evaluation times from visiting consulting personnel, and postponed follow-up appointments for general medical conditions. I remember one occasion when a patient with urinary incontinence waited 3 days until internal medicine completed its consult. These experiences remind me of the conversations I had in medical school. Some of my colleagues would say, “Psychiatric patients are difficult.” Others were honest in admitting that they were scared to even enter a psychiatric inpatient unit.

Medical comorbidities common

During one 24-hour shift, I was paged to the inpatient unit. A new admission from that afternoon was complaining of “toe pain.”

The patient had been admitted for suicidal ideation and alcohol withdrawal. He reported tripping over a concrete step 2 weeks prior to admission. Under examination, he had an open laceration with purulent, foul-smelling discharge, erythema, and edema around the wound. The patient had signs of cellulitis, had a possible fracture of the phalanx, and was at risk for osteomyelitis.

He had been medically cleared at another facility prior to his admission, where he also had complained of toe pain. At that time, however, he was told, “You are not here for that,” and the extremity was not examined during the medical clearance. I ordered a referral, imaging was completed, and antibiotic treatment was started for his infection. Unfortunately, this is not an incidental or isolated case; situations similar to this one have become more frequent than we would like for those with mental illness.

Often, psychiatric patients are overlooked and undertreated. We frequently are the only physicians who evaluate the patient and help improve their quality of life. After reviewing the literature, I found countless studies concluding that patients who have a psychiatric diagnosis often have increased medical comorbidity and even increased mortality. A review and meta-analysis published earlier this year suggested that “people with mental disorders often do not receive preventive services, such as immunizations, cancer screenings, and tobacco counseling, and often receive a lower quality of care for medical conditions” (JAMA Psychiatry 2015;72:334-41). The researchers also found that “mortality was significantly higher among people with mental disorders than among the comparison population.”

Focusing on mind, body

I knew I wanted to be a psychiatrist since my early years in training. Initially, I was drawn toward psychology, in which I completed a bachelor’s degree, but my world turned around after a conversation with the father of a high school classmate. He told me: “I commend you on your decision to want to help people; however, I would like to give you food for thought. If your goal is to be of service to your patients and provide care, it would be to their benefit to address not only the mind but also the body” (which, coincidentally, is the theme of this year’s American Psychiatric Association meeting in Toronto.)

At that time, I was weighing becoming a clinician versus a physician; after all, both have instrumental roles in treatment. Yet, those words resonate now in my life for a new reason, namely, that my duty as an advocate for mental health is not only to treat psychiatric disorders but also to work toward treating general medical conditions.

I have been fortunate to cross paths with mentors who helped strengthen my commitment to well-rounded care and a multidisciplinary approach for the mentally ill. I am thankful to have worked with Dr. Jill Williams, who stressed the need to treat tobacco dependence, and Dr. Anthony Tobia, who emphasized the need to rule out substance- and medication-induced disorders prior to treatment. I have had the pleasure of working with many other attending psychiatrists who not only focused on psychiatric symptoms and diagnosis but stressed the need to address the medical care of our patients.

If I can understand my patients by learning about human behavior, conditioning, defense mechanisms, and interpersonal relationships and also focus on pathophysiology, comorbid conditions, differential diagnosis, and exacerbating medical conditions, I will be able to give them the best medical care possible.

Dr. Poulsen, a second-year psychiatry resident at the Robert Wood Johnson Medical School, Piscataway, N.J., is interested in cultural psychiatry and advocacy, and in pursuing a fellowship in child and adolescent psychiatry. After obtaining a bachelor of science degree at the University of Florida, Gainesville, he earned a medical degree at the University of Puerto Rico. He is currently serving in multiple leadership positions, including vice president of the New Jersey Psychiatric Association (NJPA) Residents Chapter and NJPA chapter advocacy coordinator. In addition, he has been selected as resident-fellow representative of the APA’s Area 3.

The first year of residency came faster than I had expected and concluded just as quickly. At times, it felt like medical school, with different rotations, adjusting to newly formed teams, dealing with the pressures of getting the right diagnosis and treatment, managing the unrelenting speed of rounds, and trying to make a difference for the better. I must be honest – there were times when I was counting down the days for the rotation to end so that I could begin focusing and working directly in the mental health field.

Now, in my second year, the pace has improved, and the rotations resemble the work and patient population that I chose during the match process. Nonetheless, I am thankful for the time spent and the knowledge gained during my intern year, because it is only now that I understand the true value of my first-year experiences and the need to continue getting a well-rounded medical education for the benefit of my patients.

During my second year of residency, I have come across multiple instances of health disparities for people with mental illness. While working in several inpatient units, I have witnessed delayed time of visit from medical/surgical or ob.gyn. consults, shorter evaluation times from visiting consulting personnel, and postponed follow-up appointments for general medical conditions. I remember one occasion when a patient with urinary incontinence waited 3 days until internal medicine completed its consult. These experiences remind me of the conversations I had in medical school. Some of my colleagues would say, “Psychiatric patients are difficult.” Others were honest in admitting that they were scared to even enter a psychiatric inpatient unit.

Medical comorbidities common

During one 24-hour shift, I was paged to the inpatient unit. A new admission from that afternoon was complaining of “toe pain.”

The patient had been admitted for suicidal ideation and alcohol withdrawal. He reported tripping over a concrete step 2 weeks prior to admission. Under examination, he had an open laceration with purulent, foul-smelling discharge, erythema, and edema around the wound. The patient had signs of cellulitis, had a possible fracture of the phalanx, and was at risk for osteomyelitis.

He had been medically cleared at another facility prior to his admission, where he also had complained of toe pain. At that time, however, he was told, “You are not here for that,” and the extremity was not examined during the medical clearance. I ordered a referral, imaging was completed, and antibiotic treatment was started for his infection. Unfortunately, this is not an incidental or isolated case; situations similar to this one have become more frequent than we would like for those with mental illness.

Often, psychiatric patients are overlooked and undertreated. We frequently are the only physicians who evaluate the patient and help improve their quality of life. After reviewing the literature, I found countless studies concluding that patients who have a psychiatric diagnosis often have increased medical comorbidity and even increased mortality. A review and meta-analysis published earlier this year suggested that “people with mental disorders often do not receive preventive services, such as immunizations, cancer screenings, and tobacco counseling, and often receive a lower quality of care for medical conditions” (JAMA Psychiatry 2015;72:334-41). The researchers also found that “mortality was significantly higher among people with mental disorders than among the comparison population.”

Focusing on mind, body

I knew I wanted to be a psychiatrist since my early years in training. Initially, I was drawn toward psychology, in which I completed a bachelor’s degree, but my world turned around after a conversation with the father of a high school classmate. He told me: “I commend you on your decision to want to help people; however, I would like to give you food for thought. If your goal is to be of service to your patients and provide care, it would be to their benefit to address not only the mind but also the body” (which, coincidentally, is the theme of this year’s American Psychiatric Association meeting in Toronto.)

At that time, I was weighing becoming a clinician versus a physician; after all, both have instrumental roles in treatment. Yet, those words resonate now in my life for a new reason, namely, that my duty as an advocate for mental health is not only to treat psychiatric disorders but also to work toward treating general medical conditions.

I have been fortunate to cross paths with mentors who helped strengthen my commitment to well-rounded care and a multidisciplinary approach for the mentally ill. I am thankful to have worked with Dr. Jill Williams, who stressed the need to treat tobacco dependence, and Dr. Anthony Tobia, who emphasized the need to rule out substance- and medication-induced disorders prior to treatment. I have had the pleasure of working with many other attending psychiatrists who not only focused on psychiatric symptoms and diagnosis but stressed the need to address the medical care of our patients.

If I can understand my patients by learning about human behavior, conditioning, defense mechanisms, and interpersonal relationships and also focus on pathophysiology, comorbid conditions, differential diagnosis, and exacerbating medical conditions, I will be able to give them the best medical care possible.

Dr. Poulsen, a second-year psychiatry resident at the Robert Wood Johnson Medical School, Piscataway, N.J., is interested in cultural psychiatry and advocacy, and in pursuing a fellowship in child and adolescent psychiatry. After obtaining a bachelor of science degree at the University of Florida, Gainesville, he earned a medical degree at the University of Puerto Rico. He is currently serving in multiple leadership positions, including vice president of the New Jersey Psychiatric Association (NJPA) Residents Chapter and NJPA chapter advocacy coordinator. In addition, he has been selected as resident-fellow representative of the APA’s Area 3.