LE1TERS
Conditions
Not
SIR: John
their
study
(1),
found
Attributable
to a Mental
de Figueiredo,
M.
M.D.,
on conditions
not
that
with
persons
Environmental
Disorder
Sc.D.,
attributable
and associates,
to a mental
family
problems
in
without
mental disorders constituted about 20% of all individuals (N=382) admitted to an outpatient psychiatric clinic during a 2-year period. The authors suggested that more research was needed on the patterns of use of psychiatric services by mdividuals with DSM-III V code conditions.
I have ing our
recently public
conditions
concluded
and
criteria,
a review
psychiatric
without
I reviewed
of the persons attendall DSM-III-R V code disorders. Using DSM-III-R
service
with
mental
records
of all new
patients
who
had
at-
tended our service from January to December 1990. I found 490 new patients; only 45 (9.18%) had unequivocal DSMIII-R V code conditions without mental disorders, of which 25 (5.10% of total cases) were family problems. Twentyseven (60%) of these 45 patients had been seen repeatedly by psychiatrists (the mean number of visits was 8.68 during 1 year); 20 patients had been treated with psychotropic drugs (according to my view, inappropriately) and support-
ing psychotherapy; and two had been referred to a psychologist for cognitive psychotherapy. Reviewing case notes of the last S years, I found that attendance for family or social problems had increased gradually (from about 6% in 1986 to 9.18% in 1990). The proportion of patis with DSMIII-R V code conditions was similar to that obsrved in other Italian services (presentation by R. Chiccchio et al. at a conference
in Naples,
Italy,
1989).
Unlike Dr. de Figuciredo and associates, who found that patients without mental disorders who had family problems were mostly referred by their families, I found that only 26% were referred by their own families, 15% were self-referred, and over 37% were referred by their family doctors or by other physicians. To me this suggests that nonpsychiatnic physicians
in our
of a mental conditions
region
health without
do not
have
a clear
idea
service.
Patients
with
mental
disorders
are
den for psychiatric services, consuming more appropriately for more severe they represent almost 1 0% of patients year.
of the
function
DSM-III-R clearly
V code
a heavy
in Psychiatric
Disorders
article “Genetics and Psychiatry: An Unheralded on the Environment” by David Reiss, M.D., and associates ( 1 ) provided an important balance of perspective to our understanding of mental disorders. However, it also reSIR: The
bur-
time that could be used disorders; in my study seen at least once in 1
flected
a somewhat
pessimistic
view
of the
contributions
raised
by the
review
by Dr.
Reiss
and
colleagues.
icy makers
mental
and
illness.
zation views
ultimately
might be the of psychiatry”
There
undercut
As Baron
may
noted,
optimal (2).
be another
“Genetic”
is not
ronment
equivalent
support
modus
basis
a synonym
for
“Coexistence
for
“biological,”
to psychosocial
factors.
nor
“environmental”
hood
processes
arc of the utmost
possibility
underscores
research
at all levels
treatment
of these
As we made
Reply
Mazzoli’s
for cross-national
patterns tnibutable
findings
at work
in utero
and
relevance
to psychiatric
the need
for broader-based,
to understand
profound
and
better
of use of psychiatric to a mental disorder. JOHN
demonstrate,
once
services
again,
comparisons for
conditions
J
Psychiatry
1 49:3,
the
of the not
at-
M. DE FIGUEIREDO, M.D., SC.D. HEIDI BOERSTLER, D.P.H., J.D. LISA O’CONNELL, B.A.
Cheshire,
Am
March
in early
child-
disorders.
This
integrative
the
devastating
etiology
1992
Conn.
and
conditions.
1 . Reiss D, Plomin R, Hetherington EM: Genetics and an unheralded window on the environment. Am J 1991; 148:283-291 2. Baron M: Genes, environment and psychopathology Biol Psychiatry 1991; 29:1055-1057 3. Pardes H, Kaufmann CA, Pincus HA, West A: Genetics chiatry: past discoveries, current dilemmas, and future Am J Psychiatry 1989; 146:435-443
psychiatry:
Psychiatry (editorial). and psydirections.
PARDES, PINCUS,
M.D. M.D. WEST
A. KAUFMANN,
M.D.
Washington,
D.C.
Treatment
SIR: I wish to take Magno Zito, Ph.D., ment refusal ( 1 ). As witness for patients
to obtain
and cross-cultural
clear
REFERENCES
orders
led me to quite SIR: Dr.
here.
and associates acknowledged that biological factors play a part in the environment, these were not given substantial attention. Ultimately, we may find that the ncurodevelopmental
not atof fam-
MAZZOLI, M.D. ForlI, Italy
two
is the cnvi-
ANNE
MARCO
need
these
for misunderstanding
for
on
in our own article (3), a wide array of psychosocial considerations must be taken into account when considering the potential effects ofgcnctics on psychiatric disorders. While Dr. Reiss
Involuntary
Associates
research
and cross-fertili-
operandi
CHARLES
1 . de Figuciredo JM, Boerstler H, O’Connell L: Conditions tributable to a mental disorder: an epidemiological study ily problems. Am J Psychiatry 1991; 148:780-783
and
Although
juxtaposing “genetic” and “environmental” perspectives may be useful for heuristic and research purposes, polarizing the two can appear to create “debates” that arc confusing to pol-
REFERENCE
de Figueiredo
of
genetics to psychiatry. This has been eloquently commented on by Miron Baron in an editorial in BiologicalPsychiatry (2). We would like to point out an important potential problem
HERBERT HAROLD ALAN
Dr.
EDITOR
Window
disorder
but
Factors
TO ThE
issue with
the conclusions
drawn
by Julie
and associates in their study of drug treata frequent independent evaluator of and who have been referred for adjudication
for involuntary different
treatment,
my experience
has
conclusions.
The high rate of withdrawn applications (“nearly onethird”) for court review of proposed involuntary treatment reported by the authors is certainly confirmed by my own experience. Their conclusion that “the court-driven system . . . is used . . . almQst exclusively for cases in which the legal outcome is clear” is contradicted by this evidence. I have found that the most common cause of withdrawal of applications for involuntary treatment has been one also noted by the authors, a lack of belief by the applicant that a “satisfactory
423
Conditions
Not
SIR: John
their
study
(1),
found
Attributable
to a Mental
de Figueiredo,
M.
M.D.,
on conditions
not
that
with
persons
Environmental
Disorder
Sc.D.,
attributable
and associates,
to a mental
family
problems
in
without
mental disorders constituted about 20% of all individuals (N=382) admitted to an outpatient psychiatric clinic during a 2-year period. The authors suggested that more research was needed on the patterns of use of psychiatric services by mdividuals with DSM-III V code conditions.
I have ing our
recently public
conditions
concluded
and
criteria,
a review
psychiatric
without
I reviewed
of the persons attendall DSM-III-R V code disorders. Using DSM-III-R
service
with
mental
records
of all new
patients
who
had
at-
tended our service from January to December 1990. I found 490 new patients; only 45 (9.18%) had unequivocal DSMIII-R V code conditions without mental disorders, of which 25 (5.10% of total cases) were family problems. Twentyseven (60%) of these 45 patients had been seen repeatedly by psychiatrists (the mean number of visits was 8.68 during 1 year); 20 patients had been treated with psychotropic drugs (according to my view, inappropriately) and support-
ing psychotherapy; and two had been referred to a psychologist for cognitive psychotherapy. Reviewing case notes of the last S years, I found that attendance for family or social problems had increased gradually (from about 6% in 1986 to 9.18% in 1990). The proportion of patis with DSMIII-R V code conditions was similar to that obsrved in other Italian services (presentation by R. Chiccchio et al. at a conference
in Naples,
Italy,
1989).
Unlike Dr. de Figuciredo and associates, who found that patients without mental disorders who had family problems were mostly referred by their families, I found that only 26% were referred by their own families, 15% were self-referred, and over 37% were referred by their family doctors or by other physicians. To me this suggests that nonpsychiatnic physicians
in our
of a mental conditions
region
health without
do not
have
a clear
idea
service.
Patients
with
mental
disorders
are
den for psychiatric services, consuming more appropriately for more severe they represent almost 1 0% of patients year.
of the
function
DSM-III-R clearly
V code
a heavy
in Psychiatric
Disorders
article “Genetics and Psychiatry: An Unheralded on the Environment” by David Reiss, M.D., and associates ( 1 ) provided an important balance of perspective to our understanding of mental disorders. However, it also reSIR: The
bur-
time that could be used disorders; in my study seen at least once in 1
flected
a somewhat
pessimistic
view
of the
contributions
raised
by the
review
by Dr.
Reiss
and
colleagues.
icy makers
mental
and
illness.
zation views
ultimately
might be the of psychiatry”
There
undercut
As Baron
may
noted,
optimal (2).
be another
“Genetic”
is not
ronment
equivalent
support
modus
basis
a synonym
for
“Coexistence
for
“biological,”
to psychosocial
factors.
nor
“environmental”
hood
processes
arc of the utmost
possibility
underscores
research
at all levels
treatment
of these
As we made
Reply
Mazzoli’s
for cross-national
patterns tnibutable
findings
at work
in utero
and
relevance
to psychiatric
the need
for broader-based,
to understand
profound
and
better
of use of psychiatric to a mental disorder. JOHN
demonstrate,
once
services
again,
comparisons for
conditions
J
Psychiatry
1 49:3,
the
of the not
at-
M. DE FIGUEIREDO, M.D., SC.D. HEIDI BOERSTLER, D.P.H., J.D. LISA O’CONNELL, B.A.
Cheshire,
Am
March
in early
child-
disorders.
This
integrative
the
devastating
etiology
1992
Conn.
and
conditions.
1 . Reiss D, Plomin R, Hetherington EM: Genetics and an unheralded window on the environment. Am J 1991; 148:283-291 2. Baron M: Genes, environment and psychopathology Biol Psychiatry 1991; 29:1055-1057 3. Pardes H, Kaufmann CA, Pincus HA, West A: Genetics chiatry: past discoveries, current dilemmas, and future Am J Psychiatry 1989; 146:435-443
psychiatry:
Psychiatry (editorial). and psydirections.
PARDES, PINCUS,
M.D. M.D. WEST
A. KAUFMANN,
M.D.
Washington,
D.C.
Treatment
SIR: I wish to take Magno Zito, Ph.D., ment refusal ( 1 ). As witness for patients
to obtain
and cross-cultural
clear
REFERENCES
orders
led me to quite SIR: Dr.
here.
and associates acknowledged that biological factors play a part in the environment, these were not given substantial attention. Ultimately, we may find that the ncurodevelopmental
not atof fam-
MAZZOLI, M.D. ForlI, Italy
two
is the cnvi-
ANNE
MARCO
need
these
for misunderstanding
for
on
in our own article (3), a wide array of psychosocial considerations must be taken into account when considering the potential effects ofgcnctics on psychiatric disorders. While Dr. Reiss
Involuntary
Associates
research
and cross-fertili-
operandi
CHARLES
1 . de Figuciredo JM, Boerstler H, O’Connell L: Conditions tributable to a mental disorder: an epidemiological study ily problems. Am J Psychiatry 1991; 148:780-783
and
Although
juxtaposing “genetic” and “environmental” perspectives may be useful for heuristic and research purposes, polarizing the two can appear to create “debates” that arc confusing to pol-
REFERENCE
de Figueiredo
of
genetics to psychiatry. This has been eloquently commented on by Miron Baron in an editorial in BiologicalPsychiatry (2). We would like to point out an important potential problem
HERBERT HAROLD ALAN
Dr.
EDITOR
Window
disorder
but
Factors
TO ThE
issue with
the conclusions
drawn
by Julie
and associates in their study of drug treata frequent independent evaluator of and who have been referred for adjudication
for involuntary different
treatment,
my experience
has
conclusions.
The high rate of withdrawn applications (“nearly onethird”) for court review of proposed involuntary treatment reported by the authors is certainly confirmed by my own experience. Their conclusion that “the court-driven system . . . is used . . . almQst exclusively for cases in which the legal outcome is clear” is contradicted by this evidence. I have found that the most common cause of withdrawal of applications for involuntary treatment has been one also noted by the authors, a lack of belief by the applicant that a “satisfactory
423
