PubMed Health⌕ Search

Biomedical subjects

P S Appelbaum

Publications and source records attributed to P S Appelbaum.

At least 37 records · Page 2Linked to original sources
PubMed2000

The history and current status of competence and informed consent in psychiatric research.

Informed consent to research has recently become a focus of public attention as questions have been raised about the adequacy of information disclosed to potential research subjects and about the competence of psychiatric research subjects to provide valid informed consent to participate in potentially high risk studies. Around the world, policies and position statements have been written to address these concerns and to offer suggestions to protect potentially vulnerable research subjects, such as persons with neuropsychiatric disorders. Relevant literature has demonstrated that a subset of persons with such disorders have significant competence-related deficits, and thus may require specific means of protection with regard to informed consent to research. Recent guidelines offered to improve the informed consent process include review of potential studies for scientific merit and potential risk, assessment of subject competence to consent to research, and the use of proxy decision-makers when subjects are deemed incompetent.

Forecasting↗
PubMed1999

Dimensional approach to delusions: comparison across types and diagnoses.

OBJECTIVE: A dimensional approach to the characterization of delusions was used to examine the use of non-content-related descriptors of delusions in revealing differences across diagnostic categories and delusion types. METHOD: Interviews with 1,136 acutely hospitalized psychiatric patients identified subjects as definitely or possibly delusional on the basis of screening questions derived from the Diagnostic Interview Schedule. Subjects with delusions were given the MacArthur-Maudsley Delusions Assessment Schedule, which generates scores on six dimensions of delusions. Delusions were classified by type, and diagnoses were assigned by using the DSM-III-R checklist. RESULTS: A total of 328 subjects (29%) were rated as definitely or possibly delusional. Their ratings on dimensions of the MacArthur-Maudsley Delusions Assessment Schedule were significantly but modestly intercorrelated. Subjects with schizophrenia generally had more intense delusions than those in other diagnostic categories. Grandiose and religious delusions were held with the greatest conviction, whereas persecutory delusions were marked by strong negative affect and a propensity to act. Factor analysis of the dimensions revealed a consistent two factor solution-"intensity and scope" and "affect and action"-regardless of the diagnosis or delusion type. CONCLUSIONS: The stability of the dimensional structure of delusions across diagnoses and delusion types suggests that even seemingly diverse delusions are more like than unlike each other; this is consistent with common etiologic mechanisms. The utility of a dimensional approach is indicated, in addition, by the ability to characterize delusions of different types and diagnoses so as to highlight therapeutic and other implications.

Acute Disease↗
PubMed1999

Competence of depressed patients for consent to research.

OBJECTIVE: The capacities of depressed patients to consent to research have been questioned by commentators who fear that the cognitive effects of a disorder may impair subjects' abilities to protect their interests. This study used a new instrument for assessing depressed patients' capacities to consent to research and examined their performance, including the relation between severity of depression and extent of impairment. METHOD: Twenty-six female outpatients with major depression (assessed with the Schedule of Affective Disorders and Schizophrenia-Lifetime Version) enrolled in a study of maintenance psychotherapy were recruited for this project. Consent-related abilities were measured with the MacArthur Competence Assessment Tool-Clinical Research (MacCAT-CR) 1 week after intake and again 8-10 weeks later. Depressive symptoms were measured by the Hamilton Depression Rating Scale. RESULTS: Almost all subjects performed quite well on the capacity measures and maintained that level of performance over time. There was no correlation between performance and degree of depressive symptoms and little relation to prior research experience. Some subjects appeared confused about the extent to which decisions about assignment to treatment groups would be made on the basis of their clinical condition rather than randomly. CONCLUSIONS: This outpatient group with major depression showed few impairments in their decision-making capacities related to research. As in other studies, some concerns were raised about subjects' appreciation that treatment assignments would not be individualized for their needs. Examination of hospitalized patients and those with psychotic depression would help to determine whether they show greater degrees of impairment. The MacCAT-CR was easily adapted for use with this depressed group.

Adult↗
PubMed1998

Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods.

BACKGROUND: The public perception that mental disorder is strongly associated with violence drives both legal policy (eg, civil commitment) and social practice (eg, stigma) toward people with mental disorders. This study describes and characterizes the prevalence of community violence in a sample of people discharged from acute psychiatric facilities at 3 sites. At one site, a comparison group of other residents in the same neighborhoods was also assessed. METHODS: We enrolled 1136 male and female patients with mental disorders between the ages of 18 and 40 years in a study that monitored violence to others every 10 weeks during their first year after discharge from the hospital. Patient self-reports were augmented by reports from collateral informants and by police and hospital records. The comparison group consisted of 519 people living in the neighborhoods in which the patients resided after hospital discharge. They were interviewed once about violence in the past 10 weeks. RESULTS: There was no significant difference between the prevalence of violence by patients without symptoms of substance abuse and the prevalence of violence by others living in the same neighborhoods who were also without symptoms of substance abuse. Substance abuse symptoms significantly raised the rate of violence in both the patient and the comparison groups, and a higher portion of patients than of others in their neighborhoods reported symptoms of substance abuse. Violence in both patient and comparison groups was most frequently targeted at family members and friends, and most often took place at home. CONCLUSIONS: "Discharged mental patients" do not form a homogeneous group in relation to violence in the community. The prevalence of community violence by people discharged from acute psychiatric facilities varies considerably according to diagnosis and, particularly, co-occurring substance abuse diagnosis or symptoms.

Adolescent↗
PubMed1998

Civil commitment of the anorexic patient.

Involuntary commitment appears to be an infrequently used intervention with anorexic patients, in part because of clinicians' uncertainty about its applicability to this population. In contrast to overtly suicidal patients, anorexic patients typically fail to express an intent to harm themselves, although their actions may result in severe harm. Examination of the language of civil commitment statutes, however, suggests that when the behavior of anorexic patients endangers their lives, they will usually be committable under grave disability standards. This appears to comport with the practices of experts in the treatment of anorexia, and with practices in other countries as well. Involuntary commitment should be used as an approach of last resort, when patients decline voluntary hospitalization and their physical safety is at risk. Moreover, civil commitment should probably also be limited to circumstances in which therapeutic gain is likely from hospitalization. Many severely ill anorexic patients will lack competence to make treatment decisions on their own behalf, allowing involuntary feeding and other procedures to take place, if necessary. Civil commitment is a tool that can legitimately be used in emergent situations with anorexic patients.

Adult↗
PubMed1998

Competence to consent to voluntary psychiatric hospitalization: a test of a standard proposed by APA. American Psychiatric Association.

OBJECTIVE: In the wake of the U.S. Supreme Court's 1990 decision in Zinermon v. Burch, renewed attention has been given to capacities patients must have to be considered competent to consent to voluntary hospitalization. An American Psychiatric Association (APA) task force suggested that strong policy interests support the establishment of a low threshold for competence in this situation. The study examined whether, as previous research suggested, patients would have difficulty meeting even this lenient standard. METHODS: One hundred voluntarily hospitalized psychiatric patients were read two brief paragraphs, one explaining the purposes of psychiatric hospitalization and and the other explaining policies for discharge. The paragraphs' readability measured about eighth-grade level. After each paragraph, participants were read two sets of questions, one testing recall of the presented information and the other testing recognition of the information in a true-false format. The scores of patients grouped by selected demographic and clinical variables were compared. RESULTS AND CONCLUSIONS: The vast majority of patients were able to comprehend the information that the APA task force suggested was relevant to their decision. However, a subgroup of patients who were initially admitted involuntarily had significantly poorer performance and may constitute a group who need special educational efforts focused on the consequences of voluntary admission.

Adult↗