February 2004: This Month's Highlights
DSM-V Development: Should Patients Participate?
In this month's lead article, John Z. Sadler, M.D., and Bill Fulford, D.Phil., M.B., summarize arguments for and against the inclusion of patients and family members on committees that are working to produce the next edition of DSM. The authors conclude that psychiatry should seriously consider such a step. "Genuine and direct" contributions by patients and their families would create a heightened sense of ownership in the outcome of the process and in the manual's acceptability, they contend. They also point out that DSM is a public policy instrument as well as a scientific document, and they argue that its development should therefore embrace a consensus-building ethic—one that reflects democratic political values, such as openness, citizen participation, and due process (see page 133). In Taking Issue, Robert L. Spitzer, M.D., who was instrumental in creating the science-based DSM development process in the 1970s, calls these arguments "politically correct nonsense" that ignore the realities of the revision process (see page 113).
Therapeutic Limit Setting and Outcomes
Most mental health professionals have encountered patients who are experiencing problems that are so difficult that helping them requires setting restrictions on their behaviors for their own best interests. Robert A. Rosenheck, M.D., and Michael S. Neale, Ph.D., studied whether five types of limit-setting interventions would lead to better outcomes in a sample of more than 1,500 veterans in assertive community treatment programs. The interventions included withholding certain types of assistance; behavioral contracting; calling on external authorities, such as probation officers; setting up a representative payee; and using civil commitment to force hospitalization. Analysis of six-month follow-up data indicated that all five types of limit-setting interventions were associated with significantly poorer outcomes. The authors acknowledge the limitations of their study and caution that their findings do not show that limit setting is harmful. However, they note that a fair test criterion for use of these interventions is that patients who receive them should do at least as well as those who do not and that their findings did not reflect this "modest objective of outcome parity" (see page 139).
Ethnic Disparities in the Prescription of Atypicals
By 2050 more than half of the U.S. population will be of African-American, Latino, Asian-American, Pacific-Islander, or Native-American descent. Recent studies have shown that individuals from ethnic minority groups who have schizophrenia are less likely to receive accurate diagnoses and, when they do, they are less likely to receive newer antipsychotics that may lead to better outcomes. A group of researchers who analyzed Texas Medicaid claims data for more than 3,500 patients with schizophrenia report that African Americans were significantly less likely than whites to receive the second-generation antipsychotics olanzapine and risperidone—they received haloperidol instead. The authors examine reasons that might account for this disparity, including differences in symptom expression and discrimination (see page 151).
Prescription of Atypicals and Anticonvulsants
Anticonvulsant medications, such as phenytoin and carbamazepine, are frequently prescribed along with atypical antipsychotics to prevent seizures or to reduce potential violence among psychotic patients. Both medications are also prescribed for patients with bipolar disorder. In this month's Psychopharmacology column, Jose de Leon, M.D., describes the mechanisms by which certain anticonvulsants modify patients' metabolism of frequently used atypical antipsychotic agents. Clinicians who add or discontinue an anticonvulsant should carefully monitor blood levels of antipsychotics to ensure that their patients continue to receive appropriate dosages. Dr. de Leon summarizes recent research findings in a helpful table that provides recommended "correction factors" for calculating changes in antipsychotic dosages (see page 125).
Briefly Noted…
• Analyses of data from a South Carolina initiative to understand the role of trauma in mental illness indicate that although routine screening has revealed a high rate of exposure to trauma, clinicians often fail to address trauma-related symptoms in their diagnoses and treatment plans (see page 157).
• In the Personal Accounts column, a 51-year-old Chinese-born author and teacher with bipolar disorder describes the factors that contributed to the late diagnosis and misunderstanding of her illness by clinicians in both China and North America (see page 121).
