Letters
Rita Hargrave. M.D. University of California. Davis Martinez. CA Allan J. Bernstein, M.D. Hayward Kaiser Hospital Hayward.CA References I. Wenicke JF: The side effect profile and safety of fluoxetine. J Clin Psychiatry 45:59--67, 1985 2. Cooper GL: The safety of fluoxetine: an update. Br J Psychiatry 153:77-86. 1988 3. Golden RN. Brown TM, Miller H. et al: The new antidepressants. NC Med J 49:549-554. 1988 4. Ware MR, Stewan RB: Seizure associated with fluoxetine therapy (letter). DICP 23:428. 1989 5. Rudman D, Mattson DE: Seizure disorder in the men of a Veterans Administration nursing home. J C1in Epidemiol 41 :393-399, 1988 6. Luhdorf K. Jensen LK. Plesner AM: Etiology of seizures in the elderly. Epilepsia 27:458-463,1986
On "Reasons/or Requests/or Evaluation o/Competency in a Municipal General Hospital" SIR: We read the interesting recent report by Jourdan and Glickman' with great concern about their apparent wiIlingness to accept the notion that, "Referrals for competency detennination have now become almost routine ..." because of some recent changes in physician attitudes, medicallegal considerations, and patient characteristics. We fear that such acceptance is a growing problem among CoL psychiatrists. We believe that patient characteristics have not changed much recently and that the relevant changes in physician attitudes and apparent medicolegal consideratio,!s (and therefore the rising rate of "competency" referrals) in great part represents a self-fulfiIling prophecy. That is, ifC-L psychiatrists see themselves as having an increasingly important role as judges of competency. not only will referring physicians agree with and therefore generate more such referrals, but also (and most worrisome) there is a question as to whether we and they will tend to ignore the many clinical reasons for psychiatric consultation inherent in VOLUME 33· NUMBER 2· SPRING 1992
the competency referral situation. Although we agree with the authors that referrals for evaluation of competency are frequent in municipal hospitals such as our own (23.4% or 397/1,694 of our referrals for the last 2 years), the wide variation over time in the nature of clinical situations may require that any study of this problem area have a large sample size that is obtained over a longer period. The authors studied referrals made during a 3-month period at the beginning of the academic year in teaching hospitals. That period may not be representative of the entire year, and I year may not reflect trends that are seen in the next. For example, the proportions of referrals for competency evaluation to total inpatient psychiatric consultation requests for several 3-month periods at our institution were the following: Oct - Dec Jan - Mar Apr - Jun Jul - Sep Oct - Dec Jan - Mar Apr-Jun Jul- Sep
1989 = 18.6% 1990 = 29.1% 1990 =38.0% 1990 =20.3% 1990 = 25.1% 1991 = 22.2% 1991 = 16.2% 1991 = 38.8%
These wide variations were found despite relative constancy in the rate of total consultation requests. The lowest proportion (16.2%) occurred in the period after a lecture on new state health care proxy legislation. attendance at which was mandatory for all staff physicians. We believe that the variations of rates of referrals for competency evaluation that have been reported recently do not reflect changes in the patients at risk for such referral (i.e.• hospitalized people in general). Patients selected by their physicians for such referrals might vary considerably over time and among institutions. For example, in the previous studl to which Jourdan and Glickman refer, which was co-authored by one of us (RCG) at another institution, only 3.3% of consultation requests over a 5-year period were explicitly related to competency concerns, most of those requests led to diagnosis of organic mental disorders associated with moderately severe cognitive impainnents, and the most com237
Letters
mon area of concern was related to capacity for self-care and involuntary referrals to nursing homes, thus reflecting that the patients selected for consultation were quite different from those reported by Jourdan and Glickman. The proportion of consultation requests for competency evaluation in the previous study2 was similar to that reported in other contemporary studies. These considerations lead us to hypothesize that there is a "baseline" rate of consultations that we should regard as appropriate for evaluation of capacity to make judgments in the presence of major mental disorders and that rates of referral that are significantly higher than that reflect problems unrelated to the patients themselves. For example, Jourdan and Glickman restate the observation of Wise3 that problems in doctor-patient relationships are often the appropriate focus of psychiatric consultations performed for patients who do not accept medical advice. Such problems may be on the rise, and, if so, we should not regard them as side issues during competency consultations. Rather, they are often the only important issues that we should agree to address. One of us has opined in that previous report2 that, "In the case of referrals for competency evaluation, complex legal, ethical, and practical issues may best be addressed by other physicians, ethicists, lawyers, social workers, and the legal system. We believe that the appropriate role for the psychiatrist in such matters is to diagnose the psychiatric disorders and to advise the primary physician about treatment." We would now add to that our belief that the competency referral usually represents the physician's request for some type of help with a confusing and/or disturbing patient in a distressing situation, that it is the consultant's job to define ways in which to assist the referring physicians (which may be more important than the type of help they think they need),4,5 and that the more we behave as pseudojudges the more will we become pseudopsychiatrists. Ronald C. Golinger. M.D. Maria L. Tiamson. M.D. Ethan Kass. D.O. Nassau County Medical Center East Meadow, NY 238
References Jourdan JB. Glickman L: Reasons for requests for evaluation of competency in a municipal general hospital. Psychosomatics 32:413-416.1991 2. Golinger RC. Fedoroff JP: Characteristics of patients referred to psychiatrists for competency evaluations. Psychosomatics 30:296-299. 1989 3. Wise TN: Psychiatric management of patients who threaten to sign out against medical advice. Int J Psychiatry Med 5:153-160.1974 4. Lipowski ZJ: Review of consultation psychiatry and psychosomatic medicine: I. General principles. Psychosom Med29:153-171.1967 5. Golinger R. Teitelbaum ML. Folstein MF: Clarity of request for consultation: its relationship to psychiatric diagnosis. Psychosomatics 26:649-650. 1985 I.
In Reply SIR: We welcome the opportunity to reply to the letter of Golinger et al. We agree and have stated that the increase in requests to evaluate competency is due to changes in physician attitudes and medicolegal considerations. We, however, believe that in emergencies, when there is no time to obtain a judge's decision, psychiatrists should decide on a patient's competency to accept or refuse treatment or leave the hospital. We do not understand how this question "may best be addressed by other physicians, ethicists, lawyers, social workers, and the legal system."In our legal system only physicians have the authority and responsibility to decide competency in emergencies. The other professionals mentioned do not. Golinger et al. should express their view that psychiatrists should not act as judges of competency in emergency situations not only to us, but to psychiatrists in psychiatric emergency rooms who judge whether a patient is competent to refuse admission and to psychiatrists in psychiatric inpatient units who judge whether a patient is competent to refuse medication or additional hospitalization. As these psychiatrists also are determining competency to refuse treatment. are they also. by behaving as "pseudojudges," behaving as "pseudopsychiatrists"? The point of our report is that nonpsychiatric attending physicians are requesting competency PSYCHOSOMATICS
Rita Hargrave. M.D. University of California. Davis Martinez. CA Allan J. Bernstein, M.D. Hayward Kaiser Hospital Hayward.CA References I. Wenicke JF: The side effect profile and safety of fluoxetine. J Clin Psychiatry 45:59--67, 1985 2. Cooper GL: The safety of fluoxetine: an update. Br J Psychiatry 153:77-86. 1988 3. Golden RN. Brown TM, Miller H. et al: The new antidepressants. NC Med J 49:549-554. 1988 4. Ware MR, Stewan RB: Seizure associated with fluoxetine therapy (letter). DICP 23:428. 1989 5. Rudman D, Mattson DE: Seizure disorder in the men of a Veterans Administration nursing home. J C1in Epidemiol 41 :393-399, 1988 6. Luhdorf K. Jensen LK. Plesner AM: Etiology of seizures in the elderly. Epilepsia 27:458-463,1986
On "Reasons/or Requests/or Evaluation o/Competency in a Municipal General Hospital" SIR: We read the interesting recent report by Jourdan and Glickman' with great concern about their apparent wiIlingness to accept the notion that, "Referrals for competency detennination have now become almost routine ..." because of some recent changes in physician attitudes, medicallegal considerations, and patient characteristics. We fear that such acceptance is a growing problem among CoL psychiatrists. We believe that patient characteristics have not changed much recently and that the relevant changes in physician attitudes and apparent medicolegal consideratio,!s (and therefore the rising rate of "competency" referrals) in great part represents a self-fulfiIling prophecy. That is, ifC-L psychiatrists see themselves as having an increasingly important role as judges of competency. not only will referring physicians agree with and therefore generate more such referrals, but also (and most worrisome) there is a question as to whether we and they will tend to ignore the many clinical reasons for psychiatric consultation inherent in VOLUME 33· NUMBER 2· SPRING 1992
the competency referral situation. Although we agree with the authors that referrals for evaluation of competency are frequent in municipal hospitals such as our own (23.4% or 397/1,694 of our referrals for the last 2 years), the wide variation over time in the nature of clinical situations may require that any study of this problem area have a large sample size that is obtained over a longer period. The authors studied referrals made during a 3-month period at the beginning of the academic year in teaching hospitals. That period may not be representative of the entire year, and I year may not reflect trends that are seen in the next. For example, the proportions of referrals for competency evaluation to total inpatient psychiatric consultation requests for several 3-month periods at our institution were the following: Oct - Dec Jan - Mar Apr - Jun Jul - Sep Oct - Dec Jan - Mar Apr-Jun Jul- Sep
1989 = 18.6% 1990 = 29.1% 1990 =38.0% 1990 =20.3% 1990 = 25.1% 1991 = 22.2% 1991 = 16.2% 1991 = 38.8%
These wide variations were found despite relative constancy in the rate of total consultation requests. The lowest proportion (16.2%) occurred in the period after a lecture on new state health care proxy legislation. attendance at which was mandatory for all staff physicians. We believe that the variations of rates of referrals for competency evaluation that have been reported recently do not reflect changes in the patients at risk for such referral (i.e.• hospitalized people in general). Patients selected by their physicians for such referrals might vary considerably over time and among institutions. For example, in the previous studl to which Jourdan and Glickman refer, which was co-authored by one of us (RCG) at another institution, only 3.3% of consultation requests over a 5-year period were explicitly related to competency concerns, most of those requests led to diagnosis of organic mental disorders associated with moderately severe cognitive impainnents, and the most com237
Letters
mon area of concern was related to capacity for self-care and involuntary referrals to nursing homes, thus reflecting that the patients selected for consultation were quite different from those reported by Jourdan and Glickman. The proportion of consultation requests for competency evaluation in the previous study2 was similar to that reported in other contemporary studies. These considerations lead us to hypothesize that there is a "baseline" rate of consultations that we should regard as appropriate for evaluation of capacity to make judgments in the presence of major mental disorders and that rates of referral that are significantly higher than that reflect problems unrelated to the patients themselves. For example, Jourdan and Glickman restate the observation of Wise3 that problems in doctor-patient relationships are often the appropriate focus of psychiatric consultations performed for patients who do not accept medical advice. Such problems may be on the rise, and, if so, we should not regard them as side issues during competency consultations. Rather, they are often the only important issues that we should agree to address. One of us has opined in that previous report2 that, "In the case of referrals for competency evaluation, complex legal, ethical, and practical issues may best be addressed by other physicians, ethicists, lawyers, social workers, and the legal system. We believe that the appropriate role for the psychiatrist in such matters is to diagnose the psychiatric disorders and to advise the primary physician about treatment." We would now add to that our belief that the competency referral usually represents the physician's request for some type of help with a confusing and/or disturbing patient in a distressing situation, that it is the consultant's job to define ways in which to assist the referring physicians (which may be more important than the type of help they think they need),4,5 and that the more we behave as pseudojudges the more will we become pseudopsychiatrists. Ronald C. Golinger. M.D. Maria L. Tiamson. M.D. Ethan Kass. D.O. Nassau County Medical Center East Meadow, NY 238
References Jourdan JB. Glickman L: Reasons for requests for evaluation of competency in a municipal general hospital. Psychosomatics 32:413-416.1991 2. Golinger RC. Fedoroff JP: Characteristics of patients referred to psychiatrists for competency evaluations. Psychosomatics 30:296-299. 1989 3. Wise TN: Psychiatric management of patients who threaten to sign out against medical advice. Int J Psychiatry Med 5:153-160.1974 4. Lipowski ZJ: Review of consultation psychiatry and psychosomatic medicine: I. General principles. Psychosom Med29:153-171.1967 5. Golinger R. Teitelbaum ML. Folstein MF: Clarity of request for consultation: its relationship to psychiatric diagnosis. Psychosomatics 26:649-650. 1985 I.
In Reply SIR: We welcome the opportunity to reply to the letter of Golinger et al. We agree and have stated that the increase in requests to evaluate competency is due to changes in physician attitudes and medicolegal considerations. We, however, believe that in emergencies, when there is no time to obtain a judge's decision, psychiatrists should decide on a patient's competency to accept or refuse treatment or leave the hospital. We do not understand how this question "may best be addressed by other physicians, ethicists, lawyers, social workers, and the legal system."In our legal system only physicians have the authority and responsibility to decide competency in emergencies. The other professionals mentioned do not. Golinger et al. should express their view that psychiatrists should not act as judges of competency in emergency situations not only to us, but to psychiatrists in psychiatric emergency rooms who judge whether a patient is competent to refuse admission and to psychiatrists in psychiatric inpatient units who judge whether a patient is competent to refuse medication or additional hospitalization. As these psychiatrists also are determining competency to refuse treatment. are they also. by behaving as "pseudojudges," behaving as "pseudopsychiatrists"? The point of our report is that nonpsychiatric attending physicians are requesting competency PSYCHOSOMATICS
