Objective Prolonged elevations of glucocorticoids have been linked to the effective disturbances experienced by patients with Cushing's syndrome. Major depression has been most commonly reported in patients with endogenous Cushing's syndrome. The purpose of this study was to determine whether these patients experience melancholic or 'atypical' subtype depression and to determine relations between current psychological functioning and factors such as duration and severity of Cushing's syndrome. Design and patients We examined 33 adult patients with documented Cushing's syndrome and 17 hospitalized, matched controls, using standardized structured interviews and tests. Results During the active phase of Cushing's syndrome (prior to and/or on admission), 66.7% of all patients reported histories meeting criteria for a psychiatric diagnosis. Of those with a diagnosis during Cushing's syndrome, 50% reported major depression. Upon presentation to this institution, atypical depression was the most common diagnosis involving 51.5% (n =17) of all enrolled patients. Of the 17 with atypical depression, 8 reported a co-morbid psychiatric disorder. The duration of Cushing's syndrome was an important factor in predicting whether patients sought psychological intervention or met criteria for psychiatric diagnosis. Conclusion Patients with active endogenous Cushing's syndrome exhibit significant psychopathology expressed primarily by atypical depression. Longer duration of Cushing's syndrome may place them at increased risk of such psychopathology.

Psychopathology in patients with endogenous Cushing's syndrome: ‘atypical’ or melancholic features

Competence to stand trial is a legal construct used to identify those criminal defendants who have the requisite mental capacity to understand the nature and objective of the proceedings against them and to participate rationally in preparing their defense. This Practice Guideline has described how psychiatrists should evaluate individuals concerning their competence to stand trial. The Guideline describes acceptable forensic psychiatric practice for such evaluations. Where possible, it specifies standards of practice and principles of ethics and also emphasizes the importance of analyzing an individual defendant's case in the context of statutes and case law applicable in the jurisdiction where the evaluation takes place. The recommendations in the Guideline both reflect and are limited by evolving case law, statutory requirements, legal publications, and the current state of psychiatric knowledge. The authors have taken note of nationally applicable case law, federal constitutional standards, statutory language, and federal and state interpretations of the rights or statutes, recognizing that jurisdictions may differ in their specific interpretation or application of statutes or general constitutional standards. The review of cases concerning specific psychiatric diagnoses illustrates general U.S. trends, and psychiatrists must remain cognizant of their jurisdictions' interpretations of statutes or constitutional requirements. By surveying a variety of practices and approaches to data gathering and case analysis, the authors believe that this Guideline will stimulate additional collegial discussion about what is necessary and sufficient for adequate evaluations of adjudicative competence. The notion that psychiatrists should apply expertise to competence assessments stems from the principal that, before allowing a defendant to face criminal prosecution and possible punishment, courts need reasonable assurance--based, if necessary, on a careful, individualized evaluation--that the defendant has adequate mental capacity to make a defense. At a minimum, a psychiatrist's opinion about adjudicative competence should reflect an understanding of the jurisdictional standard and of how the defendant's mental condition affects competence as defined with the jurisdiction. The psychiatrist's report should clearly describe the opinion and the reasoning that leads to it. Psychiatrists who provide mental health expertise concerning adjudicative competence give trial courts information needed to assure that defendants can appropriately protect themselves and that criminal proceedings will be accurate, dignified,and just.

https://aapl.org/docs/pdf/Competence%20to%20Stand%20Trial.pdf

AAPL Practice Guideline for the Forensic Psychiatric Evaluation of Competence to Stand Trial

The suicidal patient: Clinical and legal standards of care, 3rd ed.

The authors examined the records for 1975 of 87 pretrial commitments to Worcester State Hospital under a 1971 revision of the Massachusetts law regarding such commitments They also compiled statistics on all admissions to the hospital for 1966-1975 They found that only 2 of the 87 pretrial commitments resulted in a final court disposition of commitment and that pretrial commitments increased during 1972-1975 in contrast to a decrease in other kinds of admissions On the basis of these findings the authors suggest that serious attention be paid to arguments that pretrial commitment serves to control and sequester deviants Dr Alan A Stone comments on the authors' presentation

The process of criminal commitment for pretrial psychiatric examination: an evaluation.

BACKGROUND The study aimed to define the characteristics and assess the clinical predictability and possible prevention of psychiatric in-patient suicides.

METHOD The coroner's files on all suicides in the Greater Montreal Region from 1 April 1986 to 31 March 1991 were examined. The medical records of each case of suspected in-patient suicide were then reviewed and rated for predictability and preventive measures taken.

RESULTS A total of 3079 suicides were recorded over this five-year period (mean annual rate of 16.4 per 100,000 inhabitants). Of these, 104 (3.4%) involved hospital in-patients. Nearly half (48%) of these in-patient suicides occurred outside the hospital setting. The methods most frequently employed were hanging (36%) and jumping from high places (24%). Patients suffering from an affective disorder (45%) or schizophrenia (35%) comprised the majority of the sample. Suicides were significantly more predictable in general hospital psychiatric wards. Suicide prevention measures did not differ significantly across settings.

CONCLUSIONS The majority of in-patient suicides were not highly predictable. For highly predictable suicides, the results underline the importance of actively treating and protecting these patients.

One hundred in-patient suicides.

Liability of hospital and psychiatrist in suicide.

Thirty-two cases of suicide or self-injury in which I served as a medicolegal consultant are reviewed. Suits involving suicide have increased to 18 to 25 percent of psychiatric practice litigation. The demography of suicide is discussed and contrasted with the population studied; this study stresses the problem of the young, unstable, and poorly predictable patient. Consider­ ations in risk management include adequate and timely records, documen­ tation for decisions (particularly involving privileges), clear hospital policies and procedures, and adherence to those policies. In this study, at least 10 percent of the cases did reflect defects in care by the psychiatrist or hospital staff. Lawsuits against psychiatrists have increased rapidly. In 1975, an AMA study indicated that the claims rate against psychiatrists was 2.27 percent per year, the second lowest of physician groups. 1 A claim means that an action against a physician has been reported to an insurance company, and the percentage refers to the ratio of claims as related to numbers in that specialty in a one-year period. Slawson 2 reported that claims against psy­ chiatrists have increased from 2 percent in 1978 to 4 percent in 1983 (the rate for non-psychiatrists is now about 25 percent). Psychiatric malpractice costs in five years have increased four-fold; in that series, negligence leading to suicide was invoked in 18 percent of threatened suits against psychiatrists. Bellamy3 reported earlier that 14 percent of claims against psychiatrists involved suicide. Slawson, in another article,4 stated that claims in Southern California against psychiatrists for all causes from 1958 to 1967 were only 1.5 percent (1.5 per hundred psychiatrists per year), increasing by 1979 to 4 percent per year in California, with 25% involving suicide. s I have previously discussed the law regarding suicide liability and how it should reasonably be applied.6-9 Litman 10 noted that 1 percent of suicides occurred in hospitals, general and psychiatric; with one-third resulting in lawsuits, of which one-half were against psychiatric hospitals. He analyzed seven lawsuits as a suicidologist expert witness. I will report on 32 cases where I was a consultant to attorneys in litigation involving suicide (includ­ ing cases of self-injury involving similar principles).

http://jaapl.org/content/jaapl/13/3/209.full.pdf

Suicide litigation and risk management: a review of 32 cases.

The responsibility of hospitals and physicians for suicide prevention continues to be a major problem confronting the health care professions. Suicide induced litigation was reviewed in 1960 and 1965 [1,2] and my purpose now is to bring up to date some of the conflicting issues characteristic of this problem.

Suicide and Civil Litigation

Various aspects of the problem of the premenstrual tension syndrome have been discussed–from medical, psychiatric, and legal viewpoints. The syndrome has been defined with comments on frequency and symptoms with some elaboration on physiological changes and theories of etiology. This in turn has been correlated as much as possible with psychiatric findings, and lastly the relationship of the syndrome to legal considerations has been briefly discussed.

Medical, psychiatric, and legal aspects of premenstrual tension.

http://jaapl.org/content/jaapl/4/2/184.full.pdf

Misuse of Psychiatry in the Criminal Courts: Competency to Stand Trial

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