Sensationalized media accounts of violent crimes committed by psychotic patients exacerbate public misconceptions about these diseases. Statistically, individuals with psychoses are more likely to be victims than perpetrators of crime. Untreated patients, especially when under the inﬂuence of alcohol or other substances, are at somewhat increased risk of violent behavior; treated patients are no more violent than the general public (192).
Management Psychotic illnesses are usually managed by psychiatrists. A primary care practitioner can assume responsibility, in consultation with a psychiatrist, for a stable patient who complies with treatment. When a patient expresses delusions, the clinician may indicate that he or she does not share these delusions, but should not debate with the patient (193–195). It is important to concentrate on the patient’s strengths. She can be humiliated easily by thoughtless epithets or behaviors that betray the expectation of violence or incompetence. Patients with severe cases must be treated with an integrated system of social services, family support, rehabilitation, general medical care, psychotherapy, and psychopharmacology. In the process of referral to a mental health professional, the primary clinician should be clear, matter-of-fact, open, and confident of the possibility of successful treatment (192).
1.
Schurman RA, Kramer PD, Mitchell JB. The hidden mental health network: treatment of mental illness by nonpsychiatrist physicians. Arch Gen Psychiatry 1985;42:89–94.
2.
Dubovsky SL. Psychotherapeutics in primary care. New York: Grune & Stratton, 1981.
3.
Berndt ER, Koran LM, Finkelstein SN, et al. Lost human capital from early-onset chronic depression. Am J Psychiatry 2000;157:940– 947.
4.
Smith I, Adkins S, Walton J. Pharmaceuticals: therapeutic review.
New York: Shearson, Lehman, Hutton International Research, 1988.
5.
Pierce C. Failure to spot mental illness in primary care is a global problem. Clin Psychiatry News 1993;21:5.
6.
Margolis RL. Nonpsychiatric house staff frequently misdiagnose psychiatric disorders in general hospital inpatients. Psychosomatics 1994;35:485–491.
7.
Perez-Stable EJ, Miranda J, Munoz RF, et al. Depression in medical outpatients: underrecognition and misdiagnosis. Arch Intern Med 1990;150:1083–1088.
8.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: American Psychiatric Press, 1994.
9.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Text revision. Washington, DC: American Psychiatric Association, 2000.
10.
Depression Guideline Panel. Depression in primary care: Vol. 1, detection and diagnosis. Clinical practice guideline no 5. AHCPR, Publication No 93-0550. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1993.
11.
Cassem NH. Depression. In: Cassem NH, ed. Massachusetts General Hospital handbook of general hospital psychiatry. St. Louis, MO: Mosby Year Book, 1991:237–268.
12.
Murphy GE. The physician’s responsibility for suicide. II: Errors of omission. Ann Intern Med 1975;82:305–309.
13.
Veith I. Hysteria: the history of a disease. Chicago: University of Chicago Press, 1965.
14.