Hudson County (NJ) superior court

A 44-year-old man with bipolar disorder and a history of suicidal behavior was hospitalized after telling the treating psychiatrist he had suicidal thoughts. Approximately 3 weeks later, the psychiatrist informed the patient he would be discharged.

Despite his objections, the patient was discharged 4 days later with the psychiatrist’s approval. This occurred even though the patient was found to be suicidal when he was evaluated that day by an in-hospital social services agency.

Two days later, the patient jumped from a 4-story building and sustained permanent partial paralysis. Subsequent treatments included spinal rod insertion, laminectomy, skin grafts, and 3 months’ rehabilitation.

The patient sued the psychiatrist for negligence for both the discharge and for inadequate medication management. The suit claimed that the prescribed mood stabilizer was dosed below therapeutic serum levels and that the psychiatrist switched the patient’s adjunctive antidepressant too close to his discharge date to determine its efficacy.

• The case was settled for $1 million.

Inappropriate drug therapy blamed for inducing fatal heart failure

Kings County (CA) superior court

A patient with severe mental illness died of congestive heart failure (CHF), and his three minor children argued that their father’s medications caused his death.

The patient’s surgeon and family practitioner observed that he had a history of acute psychosis and was taking haloperidol. He was also being treated for schizophrenia and bipolar disorder and was living in a group home. The patient was diagnosed with diabetes in 1998.

In 2000, a group home staff member observed ankle swelling and foam around the patient’s mouth. The consulting psychiatrist reduced the mood stabilizer dosage. The family physician subsequently saw the patient for complaints of cough, wheeze, dizziness, and foam on the mouth. Neither physician acknowledged the foam.

The patient was found dead the next day. Autopsy showed that he died of drug intoxication; toxicology studies showed that serum levels of two psychotropic medications were elevated.

The plaintiffs argued that the psychiatrist’s mismanagement of the psychotropics led to the patient’s death, and that the family practitioner failed to test for CHF. The psychiatrist argued that the drug levels were necessary to control the patient’s mental illness. The family practitioner questioned the autopsy conclusion and stated that relevant diagnostic studies were not ordered because the patient’s presentation was atypical for CHF.

• The jury settled in the defense’s favor.

Unattended patient sustains brain injury in attempted suicide

Unnamed county (MN) district court

A patient was hospitalized in the psychiatric unit with a diagnosis of major depressive disorder, suicidal ideation, and a defined suicide plan. The hospital psychiatrist ordered a suicide watch.

Three days after admission, hospital staff allowed the patient to use the psychiatric unit’s exercise equipment. When left unsupervised in the exercise room, the patient attempted suicide by hanging. Staff discovered and resuscitated the patient, but the hanging attempt resulted in severe anoxic brain injury, which caused permanent and total disability.

• The case was settled out of court for $2.75 million.

Bipolar teen attacks mother with knife; family blames misdiagnosis

Tarrant County (TX) district court

A 14-year-old boy was being treated in early 2000 by a psychiatric group for depression and hyperactivity, for which he was prescribed methylphenidate and paroxetine. Later that year, he became agitated and attacked his mother with a knife. He was arrested and charged with assault with a deadly weapon.

The plaintiff sued the psychiatrists for failure to diagnose his bipolar condition and showed that prescribing paroxetine without a mood stabilizer is contraindicated in bipolar patients. The defendants argued that the patient did not have bipolar disorder when the medications were prescribed.

• The jury found no negligence. Claims by the plaintiff’s mother were dismissed.

Hudson County (NJ) superior court

A 44-year-old man with bipolar disorder and a history of suicidal behavior was hospitalized after telling the treating psychiatrist he had suicidal thoughts. Approximately 3 weeks later, the psychiatrist informed the patient he would be discharged.

Despite his objections, the patient was discharged 4 days later with the psychiatrist’s approval. This occurred even though the patient was found to be suicidal when he was evaluated that day by an in-hospital social services agency.

Two days later, the patient jumped from a 4-story building and sustained permanent partial paralysis. Subsequent treatments included spinal rod insertion, laminectomy, skin grafts, and 3 months’ rehabilitation.

The patient sued the psychiatrist for negligence for both the discharge and for inadequate medication management. The suit claimed that the prescribed mood stabilizer was dosed below therapeutic serum levels and that the psychiatrist switched the patient’s adjunctive antidepressant too close to his discharge date to determine its efficacy.

• The case was settled for $1 million.

Inappropriate drug therapy blamed for inducing fatal heart failure

Kings County (CA) superior court

A patient with severe mental illness died of congestive heart failure (CHF), and his three minor children argued that their father’s medications caused his death.

The patient’s surgeon and family practitioner observed that he had a history of acute psychosis and was taking haloperidol. He was also being treated for schizophrenia and bipolar disorder and was living in a group home. The patient was diagnosed with diabetes in 1998.

In 2000, a group home staff member observed ankle swelling and foam around the patient’s mouth. The consulting psychiatrist reduced the mood stabilizer dosage. The family physician subsequently saw the patient for complaints of cough, wheeze, dizziness, and foam on the mouth. Neither physician acknowledged the foam.

The patient was found dead the next day. Autopsy showed that he died of drug intoxication; toxicology studies showed that serum levels of two psychotropic medications were elevated.

The plaintiffs argued that the psychiatrist’s mismanagement of the psychotropics led to the patient’s death, and that the family practitioner failed to test for CHF. The psychiatrist argued that the drug levels were necessary to control the patient’s mental illness. The family practitioner questioned the autopsy conclusion and stated that relevant diagnostic studies were not ordered because the patient’s presentation was atypical for CHF.

• The jury settled in the defense’s favor.

Unattended patient sustains brain injury in attempted suicide

Unnamed county (MN) district court

A patient was hospitalized in the psychiatric unit with a diagnosis of major depressive disorder, suicidal ideation, and a defined suicide plan. The hospital psychiatrist ordered a suicide watch.

Three days after admission, hospital staff allowed the patient to use the psychiatric unit’s exercise equipment. When left unsupervised in the exercise room, the patient attempted suicide by hanging. Staff discovered and resuscitated the patient, but the hanging attempt resulted in severe anoxic brain injury, which caused permanent and total disability.

• The case was settled out of court for $2.75 million.

Bipolar teen attacks mother with knife; family blames misdiagnosis

Tarrant County (TX) district court

A 14-year-old boy was being treated in early 2000 by a psychiatric group for depression and hyperactivity, for which he was prescribed methylphenidate and paroxetine. Later that year, he became agitated and attacked his mother with a knife. He was arrested and charged with assault with a deadly weapon.

The plaintiff sued the psychiatrists for failure to diagnose his bipolar condition and showed that prescribing paroxetine without a mood stabilizer is contraindicated in bipolar patients. The defendants argued that the patient did not have bipolar disorder when the medications were prescribed.

• The jury found no negligence. Claims by the plaintiff’s mother were dismissed.

Hudson County (NJ) superior court

A 44-year-old man with bipolar disorder and a history of suicidal behavior was hospitalized after telling the treating psychiatrist he had suicidal thoughts. Approximately 3 weeks later, the psychiatrist informed the patient he would be discharged.

Despite his objections, the patient was discharged 4 days later with the psychiatrist’s approval. This occurred even though the patient was found to be suicidal when he was evaluated that day by an in-hospital social services agency.

Two days later, the patient jumped from a 4-story building and sustained permanent partial paralysis. Subsequent treatments included spinal rod insertion, laminectomy, skin grafts, and 3 months’ rehabilitation.

The patient sued the psychiatrist for negligence for both the discharge and for inadequate medication management. The suit claimed that the prescribed mood stabilizer was dosed below therapeutic serum levels and that the psychiatrist switched the patient’s adjunctive antidepressant too close to his discharge date to determine its efficacy.

• The case was settled for $1 million.

Inappropriate drug therapy blamed for inducing fatal heart failure

Kings County (CA) superior court

A patient with severe mental illness died of congestive heart failure (CHF), and his three minor children argued that their father’s medications caused his death.

The patient’s surgeon and family practitioner observed that he had a history of acute psychosis and was taking haloperidol. He was also being treated for schizophrenia and bipolar disorder and was living in a group home. The patient was diagnosed with diabetes in 1998.

In 2000, a group home staff member observed ankle swelling and foam around the patient’s mouth. The consulting psychiatrist reduced the mood stabilizer dosage. The family physician subsequently saw the patient for complaints of cough, wheeze, dizziness, and foam on the mouth. Neither physician acknowledged the foam.

The patient was found dead the next day. Autopsy showed that he died of drug intoxication; toxicology studies showed that serum levels of two psychotropic medications were elevated.

The plaintiffs argued that the psychiatrist’s mismanagement of the psychotropics led to the patient’s death, and that the family practitioner failed to test for CHF. The psychiatrist argued that the drug levels were necessary to control the patient’s mental illness. The family practitioner questioned the autopsy conclusion and stated that relevant diagnostic studies were not ordered because the patient’s presentation was atypical for CHF.

• The jury settled in the defense’s favor.

Unattended patient sustains brain injury in attempted suicide

Unnamed county (MN) district court

A patient was hospitalized in the psychiatric unit with a diagnosis of major depressive disorder, suicidal ideation, and a defined suicide plan. The hospital psychiatrist ordered a suicide watch.

Three days after admission, hospital staff allowed the patient to use the psychiatric unit’s exercise equipment. When left unsupervised in the exercise room, the patient attempted suicide by hanging. Staff discovered and resuscitated the patient, but the hanging attempt resulted in severe anoxic brain injury, which caused permanent and total disability.

• The case was settled out of court for $2.75 million.

Bipolar teen attacks mother with knife; family blames misdiagnosis

Tarrant County (TX) district court

A 14-year-old boy was being treated in early 2000 by a psychiatric group for depression and hyperactivity, for which he was prescribed methylphenidate and paroxetine. Later that year, he became agitated and attacked his mother with a knife. He was arrested and charged with assault with a deadly weapon.

The plaintiff sued the psychiatrists for failure to diagnose his bipolar condition and showed that prescribing paroxetine without a mood stabilizer is contraindicated in bipolar patients. The defendants argued that the patient did not have bipolar disorder when the medications were prescribed.

• The jury found no negligence. Claims by the plaintiff’s mother were dismissed.

I am rebutting “How to reduce aggression in patients with conduct disorder” (Current Psychiatry, April 2004).

A 15-year-old ended his first two visits with me under police custody and was committed both times. After the first commitment, his grandmother filed a petition alleging unruly/delinquent behavior, and a judge ordered the boy to take his prescribed mood stabilizers. That was necessary because the hospital psychiatrist had determined that the boy was not mentally ill and that his grandmother needed parenting classes. The youth’s original diagnosis—conduct disorder and oppositional-defiant disorder (ODD)—contradicted my diagnosis: bipolar disorder, mixed.

During the second hospitalization, a psychiatrist diagnosed the youth as having attentiondeficit/hyperactivity disorder (ADHD). The doctor prescribed methylphenidate and oxcarbazepine, but the patient’s guardian did not consent to the medications.

Facing a sentence at the county juvenile detention center, the youth started taking olanzapine, 10 mg at bedtime, and lamotrigine, 25 mg bid titrated to 50 mg bid, as I had prescribed. His grandmother says that he no longer exhibits defiant behavior. At his third visit, he shook my hand and said, “Thank you for finding the right medications for me.”

I have seen hundreds of similar cases over 10 years. To paraphrase a colleague, diagnosing somebody with conduct disorder or ODD is like diagnosing a patient with a runny nose after a thorough emergency room examination.

I applaud the American Association of Community Psychiatry’s efforts to urge the American Psychiatric Association (APA) to abolish the conduct disorder diagnosis. I also support the many researchers who are requesting elimination of conduct disorder and ODD. These are not real and specific diagnoses but are alleged syndromes that express several conditions.

Manuel Mota-Castillo MD
Orlando, FL

Dr. Malone responds

It is hard to assess Dr. Mota-Castillo’s case based on the information he provided. Still, one would not refute any psychiatric syndrome by citing a single case.

Most psychiatric disorders are syndromes and affect heterogeneous groups. This is true for disorders that are more prevalent in adults—such as schizophrenia and mania—and for those that present in childhood and adolescence—such as conduct disorder, ODD, and ADHD. Heterogeneity within disorders is no doubt related to underlying individual differences in genetics and environment and contributes to differences in symptom expression and treatment response.

Dr. Mota-Castillo did not present symptoms listed under DSM-IV-TR, so it is unclear how the patient was diagnosed. Diagnoses:

• are one clinician’s impression or the consensus of several clinicians
• are based on one patient encounter or ongoing treatment
• occur with or without input from other sources, such as parents and school
• are made with or without validated structured interviews.

Conduct disorder and ODDare part of DSM diagnostic nomenclature,¹ and the APA and American Academy of Child and Adolescent Psychiatry recognize both disorders. Reducing aggression associated with either disorder has long been the most common reason for psychiatric consultation in children.²

Also, Dr. Mota-Castillo prescribed olanzapine and lamotrigine, apparently for simultaneous use. The main point of our case was to discourage polypharmacy—something most experts agree should be avoided³ —by carefully starting one drug before adding a second. When a child receives two drugs at once, we cannot know the effect of either.

In the 15-year-old’s case, as often happens, the prescribed treatment might not have changed the symptoms; some symptoms remit spontaneously.

Nor does drug response clarify diagnosis. For example, both bipolar disorder and aggression in conduct disorder (and in many other conditions) may respond to an antipsychotic.⁴ Lithium and other treatments for mania have been shown to reduce severe aggression in nonmanic children and adolescents with conduct disorder.^5,6

Richard P. Malone, MD
Associate professor
Eastern Pennsylvania Psychiatric Institute
Drexel University College of Medicine
Philadelphia, PA

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th ed-rev). Washington, DC: American Psychiatric Association, 2000.
2. Kazdin AE. Conduct disorders in childhood and adolescence, vol. 9: developmental clinical psychology and psychiatry series. Newbury Park, CA: Sage Publications, 1987.
3. Pappadopulos E, Macintyre JC II, Crismon ML, et al. Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY): Part II. J Am Acad Child Adolesc Psychiatry 2003;42(2):145–61.
4. Malone RP, Delaney MA. Psychopharmacologic interventions in children with aggression: neuroleptics, lithium, and anticonvulsants. In: Coccaro EF (ed). Aggression: assessment and treatment.New York: Marcel Dekker, 2003:331–49.
5. Malone RP, Delaney MA, Luebbert JF, et al. A double-blind placebo-controlled study of lithium in hospitalized aggressive children and adolescents with conduct disorder. Arch Gen Psychiatry 2000;57(7):649–54.
6. Campbell M, Adams PB, Small AM, et al. Lithium in hospitalized aggressive children with conduct disorder: a double-blind and placebo-controlled study. J Am Acad Child Adolesc Psychiatry 1995;34(4):445–53.

I am rebutting “How to reduce aggression in patients with conduct disorder” (Current Psychiatry, April 2004).

A 15-year-old ended his first two visits with me under police custody and was committed both times. After the first commitment, his grandmother filed a petition alleging unruly/delinquent behavior, and a judge ordered the boy to take his prescribed mood stabilizers. That was necessary because the hospital psychiatrist had determined that the boy was not mentally ill and that his grandmother needed parenting classes. The youth’s original diagnosis—conduct disorder and oppositional-defiant disorder (ODD)—contradicted my diagnosis: bipolar disorder, mixed.

During the second hospitalization, a psychiatrist diagnosed the youth as having attentiondeficit/hyperactivity disorder (ADHD). The doctor prescribed methylphenidate and oxcarbazepine, but the patient’s guardian did not consent to the medications.

Facing a sentence at the county juvenile detention center, the youth started taking olanzapine, 10 mg at bedtime, and lamotrigine, 25 mg bid titrated to 50 mg bid, as I had prescribed. His grandmother says that he no longer exhibits defiant behavior. At his third visit, he shook my hand and said, “Thank you for finding the right medications for me.”

I have seen hundreds of similar cases over 10 years. To paraphrase a colleague, diagnosing somebody with conduct disorder or ODD is like diagnosing a patient with a runny nose after a thorough emergency room examination.

I applaud the American Association of Community Psychiatry’s efforts to urge the American Psychiatric Association (APA) to abolish the conduct disorder diagnosis. I also support the many researchers who are requesting elimination of conduct disorder and ODD. These are not real and specific diagnoses but are alleged syndromes that express several conditions.

Manuel Mota-Castillo MD
Orlando, FL

Dr. Malone responds

It is hard to assess Dr. Mota-Castillo’s case based on the information he provided. Still, one would not refute any psychiatric syndrome by citing a single case.

Most psychiatric disorders are syndromes and affect heterogeneous groups. This is true for disorders that are more prevalent in adults—such as schizophrenia and mania—and for those that present in childhood and adolescence—such as conduct disorder, ODD, and ADHD. Heterogeneity within disorders is no doubt related to underlying individual differences in genetics and environment and contributes to differences in symptom expression and treatment response.

Dr. Mota-Castillo did not present symptoms listed under DSM-IV-TR, so it is unclear how the patient was diagnosed. Diagnoses:

• are one clinician’s impression or the consensus of several clinicians
• are based on one patient encounter or ongoing treatment
• occur with or without input from other sources, such as parents and school
• are made with or without validated structured interviews.

Conduct disorder and ODDare part of DSM diagnostic nomenclature,¹ and the APA and American Academy of Child and Adolescent Psychiatry recognize both disorders. Reducing aggression associated with either disorder has long been the most common reason for psychiatric consultation in children.²

Also, Dr. Mota-Castillo prescribed olanzapine and lamotrigine, apparently for simultaneous use. The main point of our case was to discourage polypharmacy—something most experts agree should be avoided³ —by carefully starting one drug before adding a second. When a child receives two drugs at once, we cannot know the effect of either.

In the 15-year-old’s case, as often happens, the prescribed treatment might not have changed the symptoms; some symptoms remit spontaneously.

Nor does drug response clarify diagnosis. For example, both bipolar disorder and aggression in conduct disorder (and in many other conditions) may respond to an antipsychotic.⁴ Lithium and other treatments for mania have been shown to reduce severe aggression in nonmanic children and adolescents with conduct disorder.^5,6

Richard P. Malone, MD
Associate professor
Eastern Pennsylvania Psychiatric Institute
Drexel University College of Medicine
Philadelphia, PA

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th ed-rev). Washington, DC: American Psychiatric Association, 2000.
2. Kazdin AE. Conduct disorders in childhood and adolescence, vol. 9: developmental clinical psychology and psychiatry series. Newbury Park, CA: Sage Publications, 1987.
3. Pappadopulos E, Macintyre JC II, Crismon ML, et al. Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY): Part II. J Am Acad Child Adolesc Psychiatry 2003;42(2):145–61.
4. Malone RP, Delaney MA. Psychopharmacologic interventions in children with aggression: neuroleptics, lithium, and anticonvulsants. In: Coccaro EF (ed). Aggression: assessment and treatment.New York: Marcel Dekker, 2003:331–49.
5. Malone RP, Delaney MA, Luebbert JF, et al. A double-blind placebo-controlled study of lithium in hospitalized aggressive children and adolescents with conduct disorder. Arch Gen Psychiatry 2000;57(7):649–54.
6. Campbell M, Adams PB, Small AM, et al. Lithium in hospitalized aggressive children with conduct disorder: a double-blind and placebo-controlled study. J Am Acad Child Adolesc Psychiatry 1995;34(4):445–53.

I am rebutting “How to reduce aggression in patients with conduct disorder” (Current Psychiatry, April 2004).

A 15-year-old ended his first two visits with me under police custody and was committed both times. After the first commitment, his grandmother filed a petition alleging unruly/delinquent behavior, and a judge ordered the boy to take his prescribed mood stabilizers. That was necessary because the hospital psychiatrist had determined that the boy was not mentally ill and that his grandmother needed parenting classes. The youth’s original diagnosis—conduct disorder and oppositional-defiant disorder (ODD)—contradicted my diagnosis: bipolar disorder, mixed.

During the second hospitalization, a psychiatrist diagnosed the youth as having attentiondeficit/hyperactivity disorder (ADHD). The doctor prescribed methylphenidate and oxcarbazepine, but the patient’s guardian did not consent to the medications.

Facing a sentence at the county juvenile detention center, the youth started taking olanzapine, 10 mg at bedtime, and lamotrigine, 25 mg bid titrated to 50 mg bid, as I had prescribed. His grandmother says that he no longer exhibits defiant behavior. At his third visit, he shook my hand and said, “Thank you for finding the right medications for me.”

I have seen hundreds of similar cases over 10 years. To paraphrase a colleague, diagnosing somebody with conduct disorder or ODD is like diagnosing a patient with a runny nose after a thorough emergency room examination.

I applaud the American Association of Community Psychiatry’s efforts to urge the American Psychiatric Association (APA) to abolish the conduct disorder diagnosis. I also support the many researchers who are requesting elimination of conduct disorder and ODD. These are not real and specific diagnoses but are alleged syndromes that express several conditions.

Manuel Mota-Castillo MD
Orlando, FL

Dr. Malone responds

It is hard to assess Dr. Mota-Castillo’s case based on the information he provided. Still, one would not refute any psychiatric syndrome by citing a single case.

Most psychiatric disorders are syndromes and affect heterogeneous groups. This is true for disorders that are more prevalent in adults—such as schizophrenia and mania—and for those that present in childhood and adolescence—such as conduct disorder, ODD, and ADHD. Heterogeneity within disorders is no doubt related to underlying individual differences in genetics and environment and contributes to differences in symptom expression and treatment response.

Dr. Mota-Castillo did not present symptoms listed under DSM-IV-TR, so it is unclear how the patient was diagnosed. Diagnoses:

• are one clinician’s impression or the consensus of several clinicians
• are based on one patient encounter or ongoing treatment
• occur with or without input from other sources, such as parents and school
• are made with or without validated structured interviews.

Conduct disorder and ODDare part of DSM diagnostic nomenclature,¹ and the APA and American Academy of Child and Adolescent Psychiatry recognize both disorders. Reducing aggression associated with either disorder has long been the most common reason for psychiatric consultation in children.²

Also, Dr. Mota-Castillo prescribed olanzapine and lamotrigine, apparently for simultaneous use. The main point of our case was to discourage polypharmacy—something most experts agree should be avoided³ —by carefully starting one drug before adding a second. When a child receives two drugs at once, we cannot know the effect of either.

In the 15-year-old’s case, as often happens, the prescribed treatment might not have changed the symptoms; some symptoms remit spontaneously.

Nor does drug response clarify diagnosis. For example, both bipolar disorder and aggression in conduct disorder (and in many other conditions) may respond to an antipsychotic.⁴ Lithium and other treatments for mania have been shown to reduce severe aggression in nonmanic children and adolescents with conduct disorder.^5,6

Richard P. Malone, MD
Associate professor
Eastern Pennsylvania Psychiatric Institute
Drexel University College of Medicine
Philadelphia, PA

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th ed-rev). Washington, DC: American Psychiatric Association, 2000.
2. Kazdin AE. Conduct disorders in childhood and adolescence, vol. 9: developmental clinical psychology and psychiatry series. Newbury Park, CA: Sage Publications, 1987.
3. Pappadopulos E, Macintyre JC II, Crismon ML, et al. Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY): Part II. J Am Acad Child Adolesc Psychiatry 2003;42(2):145–61.
4. Malone RP, Delaney MA. Psychopharmacologic interventions in children with aggression: neuroleptics, lithium, and anticonvulsants. In: Coccaro EF (ed). Aggression: assessment and treatment.New York: Marcel Dekker, 2003:331–49.
5. Malone RP, Delaney MA, Luebbert JF, et al. A double-blind placebo-controlled study of lithium in hospitalized aggressive children and adolescents with conduct disorder. Arch Gen Psychiatry 2000;57(7):649–54.
6. Campbell M, Adams PB, Small AM, et al. Lithium in hospitalized aggressive children with conduct disorder: a double-blind and placebo-controlled study. J Am Acad Child Adolesc Psychiatry 1995;34(4):445–53.