This study shows that minor tranquilizers are overused in the treatment of general medical patients, while antidepressants are not used often enough. Although the withholding of antidepressants was justified in some cases, the major reason for their nonuse was the physiclan’s lack of recognition of affective disorder. Major tranquilizers were appropriately used in most cases. Edudating nonpsychiatnist physicians in the recognition of the variants ofdepnessive disease is needed. R EFER ENCES I. Shepherd M, Davies B, Culpan RH: Psychiatric illness in the general hospital. Acta Psychiatr Scand 35:5 18-525, 1960 2. Schwab ii, Bialow M, Holzer CE, et al: Sociocultural aspects of depression in medical inpatients: I. Frequency and social variables. Arch Gen Psychiatry 17:533-538, 1967 3. Monroe A: Psychiatric illness in gynecological outpatients. Br J Psychiatry I 15:807-809, 1969 4. Sainsbury P: Psychosomatic disorders and neurosis in out-patients attending a getieral hospital. J Psychosom Res 4:261-273, 1960 5. Mellinger GD, BaIter MB, Manheimer DI: Patterns of psychotropic drug use among adults in San Francisco. Arch Gen Psychiatry 25:385-394, 1971 6. Parry Hi, BaIter MB, Mellinger GD, et al: National patterns of psychotherapeutic drug use. Arch Gen Psychiatry 28:769-783, 1973
A LAWSUIT brought against a psychiatrist by a patient is a rare event compared with the number of lawsuits brought against most other physicians. The best informa-
Dr. Trent is Chairman, APA Committee on Member Insurance and Retirement Plans. Mr. MuhI is APA Professional Liability Program Manager for the Joseph A. Britton Agency, East Orange, N.J. Address reprint requests to Dr. Trent at Box 2238, Ocean, N.J. 07712.
A m J Psychiatry /32.12, December
Holmes TH, Rahe RH: The Psychosom Res I1:213-218,
Holmes TH, Masuda Stressful Life Events: wend BS, Dohrenwend pp 45-72
Miller FT. Bentz events: a comparative 259-272
Feighner JP, in psychiatric
Johnson D: Psychiatric Investigation of Patients Admitted to Two Medical Wards. Edinburgh, University of Edinburgh, Department of Psychiatry, 1970 (doctoral dissertation)
Lesse S: Masked depression-a 1cm. Dis Nerv Syst 29: 169-173,
Cohen IH: 6:688-698,
Walton HJ: Personality correlates of a career BrJ Psychiatry 115:211-219, 1969
M: Life changes and illness susceptibility, in Their Nature and Effects. Edited by DohrenBP. New York, John Wiley & Sons, 1974, WK,
Aponte I, et al: study of rural and
Perception of urban samples.
life crisis Ibid. pp
E, Guze SB, et al: Diagnostic criteria for Arch Gen Psychiatry 26:57-63, 1972
DG, Morrison D: Useof South Med i 66:589-592,
diagnostic 968 in the
The authors outline the current position of psychiatrists in the United States regarding their vulnerability to lawsuitsfor malpractice. They review the various activities ofthe American Psychiatric Association on behalfofits members, especially its endorsement and supervision ofa professional liability programfor review and control of losses.
BaIter M B, Levine J: Nature and extent of psychotropic drug usage in the United States. Psychopharmacol Bull 5:3-14, 1969 8. Davidson JRT, Raft D, Lewis BF, et al: Psychotropic drugs on general medicine and surgical wards of a teaching hospital. Arch Gen Psychiatry 32:507-51 I, 1975 9. Zung WW: A self-rating depression scale. Arch Gen Psychiatry 12:63-70, 1965 10. Beck AT, Beamesderfer A: Assessment of depression: the depression inventory. Mod Probl Pharmacopsychiatry 7:151-169, 1974
tion available suggests that one lawsuit is brought for cvcry 5-7 years of practice for all physicians in the United States. Neurosurgical specialists may experience an average of one suit every 2 years. At the other extreme, psychiatrists in the United States are sued about once for cvcry 50-100 years of practice. Because of this low incidence of suit, most American psychiatrists have never experienced this courtroom event; in fact, there are some psychiatrists who foolishly avoid carrying adequate insurance, denying an infrequent but real danger. Within the past several months, shocking and unmanageab,le changes have occurred in the general malpractice insurance market. After 25 years ofcovcrage, the Amencan Mutual Insurance Company withdrew its coverage of physicians in northern California, and Employers Insurance of Wausau withdrew its coverage of physicians in New York State. New York’s new company, Argonaut, insured physicians for an additional premium of 93 per-
cent and then withdrew its coverage. The Professional Insurance Company of New York became insolvent, leaving many insured physicians in that state without protection under their policies. The St. Paul Insurance Company has refused to renew coverage for the State of Maryland, and the Liberty Mutual Insurance Company, after many years of coverage, has refused to continue offening insurance through the American College of Physicians. Increases of 200 percent and more in malpractice insurance premiums are not unusual throughout the United States. These chaotic changes in the malpractice insurance market have come about because of inflation, higher judgments by courts, high settlements, and stock market losses by insurance companies that have depended on investment earnings to partially support claims payments. It is an educated guess that claims against psychiatrists will increase in number and that the amount of judgments and/or settlements will be higher for several additional reasons: I. The American public is more claims conscious and feels more free to employ lawyers, believing that any injury should be compensated, whether or not it results from natural causes. 2. Modern psychiatric medication is powerful and produces many desirable results. However, undesirable side effects are also produced, some of which can be senious and irreversible. For example, phenothiazines may produce irreversible tandive dyskinesias; these have been the basis for large claims and/or judgments. One suit for compensation of tandive dyskinesia was settled out of court by a drug company and a physician together for $190,000. Two other such suits have been filed and are still in litigation. 3. Psychiatrists are engaged in more active and aggressive therapies, such as encounter groups, primal scream therapy, conditioning techniques, and sexual thenapies. Any of these could increase the psychiatrist’s cxposune to claims. 4. The consumer public is now more sophisticated; they have information on what constitutes negligence in the psychiatric and psychotherapeutic fields. 5. The legal profession has an overabundance of lawyers who are most interested in working in the lucrative professional liability area, especially in those states which have no-fault automobile insurance. In these states lawyers have lost a certain amount of automobile accident work and need another field of operation. 6. The psychiatrist is being exposed to new dangers, some of which are peculiar to his specialty: I ) civil rights; 2) responsibility for a large number of paraprofessionals (as are anesthesiologists) with the accompanying hazard of more potential accidents resulting from less personal contact with patients; 3) inability to completely supervise or even personally see all patients at all times, e.g., recently a psychiatrist who cosigned a report to a court stating that a patient he had not seen but whose social worker he had supervised was not dangerous was successfully sued for $60,000 after the patient shot himself and others (this case was settled out of court); 4) the right to
treatment, e.g., Donaldson v. O’Connor ( 1 ), with its $38,500 judgment,’ has set a precedent for suits against psychiatrists based on failure to provide treatment to patients admitted to a state hospital; 5) a new attitude toward psychiatry in state legislatures, e.g., a new law in New Jersey has created a public advocate for mental health with powers to develop any type of litigation against the state or the physicians employed by the state aimed at protecting the nights of mentally ill patients and/or obtaining adequate benefits for them; 6) the established pattern of claims against psychiatrists for suicide, wrongful commitment, improper diagnosis, alienation ofaffection, libel, slander, breach of confidentiality, injuries from ECT, and blood dyscrasias from drugs (29).
In response to the threat of unavailability of coverage to some of its members and to the problem of psychiatnists’ having been lumped together with other physicians, APA has developed its own group professional liability program. Medical societies and, more importantly, several of the larger insurance companies state that the only acceptable control and underwriting for medical professional liability insurance is through a professional society’s endorsed and supervised program. There are no national specialty groups with an endorsed program for review and control of losses other than the one for the American Psychiatric Association. The broker and manager of APA’s Loss Control Program is the Joseph A. Bnitton Agency. The experience of this agency in group professional liability insurance began in 1960. Under this agency’s management the average number of lawsuits in New Jersey for the past 14 years has been maintained at one yearly for every 20 physicians and surgeons on one for every 20 years of practice, whereas the national average is about one suit for every 5-7 years of practice. The APA program offers coverage for the individual practice of psychiatry and/or neurology as well as for partnerships and for professional associations. Professional employee coverage is included without charge; however, this does not apply to licensed physician employces. Prescribing ECT is covered; however, administening this therapy entails an additional change of 50 pencent of the individual premium. The policy will insure APA members practicing in almost all settings, such as solo private practice, clinics, and government service. The policy was designed especially to insure the Amencan psychiatrist against the peculiar hazards of the profession here, including libel, slander, false imprisonment, or unlawful detention suits, and suits resulting from cornmittec work associated with a professional society on
The judgment al by the U.S.
of this Court.
hospital as well as claims arising from bodily injury, sickness, or disease-including death. The consent of the insured is necessary for settlement of a claim or suit. A committee made up of APA members will review claims and suits to determine ifthene has been any deviation from the accepted standard of practide, and the insurance company has agreed to defend any claim that the committee requests it to on the basis of the committee’s consensus that the claim is defensible. In addition, expert claims advice is available to an insured physician who is concerned about the possibility of being sued or of having a claim made against him. A prominent feature of this program is the prospect of generating statistical data on malpractice suits against psychiatrists that will be available for educational punposes and will show the actual hazards associated with the practice of a substantial number of American psychiatnists. The program will become self-rating when adequate experience has been obtained, and premiums will eventually be adjusted to the real losses of psychiatrists only. It is planned that psychiatrists will not be required to support the premium structure of surgical specialists and other practitioners who have larger and more frequent claims brought against them. The program is underwritten by the Vigilant Insurance Company, managed by Chubb & Son, a worldwide casualty insurer currently furnishing malpractice protection to more than 20,000 physicians in the United States.
We have tried in this paper to depict the current position of American psychiatry in the area of professional liability exposure and to review the various involvements and undertakings of APA to further its services to membens and their patients.
In 1970 the President ofthe United States spearheaded an investigation of malpractice in American medicine by directing the Secretary of Health, Education, and Welfare to establish a commission to investigate, study, and report on medical malpractice. Continuing to maintain the highest possible profile among the members of the medical fraternity, APA was quick to acknowledge the importance of the commission. On December 17, 1971, one of us (C.L.T.) presented testimony before this cornmission outlining the special problems of psychiatry in the area of difficulty in obtaining coverage and the excessive premiums that result from psychiatrists’ being grouped together with nonpsychiatnic physicians and detailing the more prominent malpractice risks of psychiatnists. The commission’s voluminous report has been the basis for other organizations’ developing and continuing the work of the commission.
The National Foundation for Health Science Liability was incorporated as a group of physicians, lawyers, insuners, paraprofessionals, hospital representatives, and many other groups, including the federal government, that had an interest in the problems of health science habihity. It was proposed that this group would function as a clearinghouse and a study center for professional liability problems. To date, its efforts have not been well organized due to a lack of federal and/or foundation support. APA has also been a full and supporting member of the more recently organized Medical Liability Commission. This group ofcommissionens represents most of the national medical and hospital organizations. It is studying problems of professional liability from all possible vistas and making recommendations for appropriate changes in laws and legal procedures and stimulating projects to help cope with medical injuries and accidents. New types of insurance programs, such as policies for catastrophic medical accidents like death from diagnostic arteniography, therapeutic blood transfusions, etc., are being explored by this group.
Am I Psychiatrt’
REFERENCES I. Donaldson v O’Connor, 493 F 2d 507, 520(5th Cir 1974) 2. Appleton WS: Legal problems in psychiatric drug prescription. Am J Psychiatry 124:877-882, 1968 3. Bellamy WA: MaIactice risks confronting the psychiatrist: a nationwide fifteen-year study of appellate court cases, 1946-1961. Am J Psychiatry I 18:769-780, 1962 4. Dawidoff DJ: The Malpractice of Psychiatrists. Springfield, Ill, Charles C Thomas, 1973 5. Dawidoff Di: Some suggestions to psychiatrists for avoiding legal jeopardy. Arch Gen Psychiatry 29:699-701, 1973 6. Onaitis FL, Tennant BM: The liability of mental hospitals for the death or injury oftheir patients. Bulletin ofthe Pittsburgh Institute of Legal Medicine 3(3, part 4): 1 -25, 1969 7. Perr IN: Suicide and civil litigation. Journal of Forensic Sciences 19 (2):26l-266, 1974 8. Rothblatt HB, Leroy DH: Avoiding psychiatric malpractice. California Western Law Review 9:260-272, 1973 9. Slawson PF: Psychiatric malpractice: a regional incidence study. AmJ Psychiatry 126:1302-1305, 1970