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					Am    J Psychiatry                  /36:7,        July     1979                                                                                                                                       LETTERS                 TO       THE           EDITOR


have been               eliminated                With a census
                                             for readmitted   patients.                                                           care. They also have a right to express                themselves         about
of 22 and               an average             of one 24-hour
                                                per patient   per pass                                                            their care.
week three patients    would be out on pass each day. By al-                                                                          Many Medicaid       patients recognize       the precarious          nature
lowing patients trials outside the hospital the unit could have                                                                   oftheir   benefits  and take a vigilant    stance    toward      threatening
kept    25 rather     than                22 patients             ‘   ‘in active              treatment,’            ‘    thus    political   forces.  Our Medicaid-financed          patients       expressed
maintaining       hospital                 income.                                                                                their own feelings       in the pass restriction          matter      with no
   Allowing       non-Medicaid                         patients              to have                passes   while                prompting.               We     shared            many       of the           feelings,            but      the     patients
denying     trial discharges                        to Medicaid                patients             also gives an                 made        the decision                to speak          out and              to circulate                a petition            to
additional              realistic         basis      to     Medicaid               patients’                belief         that   Medicaid           officials.
they are treated badly.                                                                                                              Perhaps          the most             chilling         message                  in Dr. Glickman’s                       letter
    The experience    of these     patients    may have been a self-                                                              is the      proscription                against          fighting           for      health         care      rights.          We
fulfilling prophecy   precipitated      by the psychiatrists’       decision                                                      are told to be expert           in the process        of adapting         to govern-
to fight Medicaid   rather than to find new solutions.              It seems                                                      mental     control       of medical       matters.      The      ultimate       conse-
to me that one cannot       argue with the authors’         statement,       It                                             ‘ ‘   quence    of such passivity         is a state-medical          complex.        In this
is logical         not to charge     Medicaid                           when   the             patient      does    not           medical     counterpart       to the military-industrial              complex,        we
occupy          a bed. ‘ ‘ A patient     must                         be physically                 present      to re-           would dispense          homogenized        treatments      devoid       of sensitivi-
ceive care. Inpatient      staffshould  not receive       salaries     for car-                                                   ty, creativity,       and intelligence.          Real caring         would      be re-
ing for patients   who are not present.         The ‘political       factors”            ‘                                        placed by cunning          in manipulating         an oppressive        system.      UI-
that   ‘overwhelm
          ‘           time-honored     clinical    practice       and health                                                      timately,          even         this      would           fail.       I would               ask      Dr.      Gbickman,
planning        activities”      were based         on an awareness      ofthis      real-                                        when        do we fight?                When        we are told                    not to hospitalize                    needy
ity. Should          not psychiatrists          adapt   their practices,     including                                            patients?          Or      to hospitalize                 all poor             people             because           they       of-
their    billing      practices,      to reality?     Will not patients       be angry                                            fend        someone             in authority?                Or,        maybe,                when          shock          treat-
with psychiatrists    who refuse to adjust to reality,                                                      given that            ments    are the              treatment             of choice  for political                              dissenters?
patients  believe  psychiatrists       are experts     in helping                                             others to              Nonpsychiatnists                       did      show   us a better   way                             in the pass            re-
do this? Will not patients        also resent being used in                                                  a struggle           stniction        incident.  The patients     worked  tirelessly     to gain the
to prove the bureaucrats         wrong?    Nonpsychiatrists,                                                  including           support         of the whole Mount       Sinai community        in the petition
politicians,             may        occasionally            show           us a better               way.                         against the pass                  restriction.        Thanks                       to their efforts                and       oth-
                                                                                                                                  ens who    spoke                  out,      Medicaid-financed                             patients                may        now
                                                                      LEWIS        GLICKMAN,                     M.D.             again       have        passes          for therapeutic                     reasons.
                                                                                             Brooklyn,             N. Y.
                                                                                                                                                                                                    GEORGE    L. HOGBEN,                               M.D.
                                                                                                                                                                                                        TECLA    CRITELLI.                             M.D.
                                                                                                                                                                                                       RALPH    HOFFMAN,                               M.D.
Dr.      Hogben           and       Associates           Reply                                                                                                                                                   New York,                             N.Y.

    SIR: Dr. Glickman          states    that we made            ‘a decision       to fight
                                                                                     ‘


Medicaid’         and
                    ‘     used       Medicaid-financed              patients         in   ‘a                                 ‘


struggle     to prove       the bureaucrats            wrong.         He apparently          ‘ ‘                                  Thiothixene-Induced                        Tardive           Dyskinesia
based this interpretation             on his feeling that we did not adapt
to the reality of pass restriction               by developing          new methods                                                  SIR:        Tardive           dyskinesia               associated                  with         thiothixene                has
to provide      patients      with trials outside           the hospital.                                                         been described                   in the literature,  to our knowledge,      only in
    We were told to stop all passes                   immediate/v.          We had no                                             one case report                   ( I ). We have recently  observed    severe   tar-
time to develop          elaborate        alternative        procedures         for care.                                         dive        dyskinesia             in      another                patient            who          had       taken           thio-
Discharging        and readmitting            Medicaid-financed              patients     to                                      thixene.
provide     lengthy      out-of-hospital           experience       would        have re-
quired    a great deal of time in terms of coordinating                           all con-                                                 The     patient,          a 55-year-old                    woman,             was         referred          after
cerned          personnel             and     administrative                    procedures.                   We         oper-       a 3-year         history            ofjerking           ofthe            left     leg,     a I-year            history
ated in a crisis atmosphere                           that prevented,   at least during the                                          of almost constant      movement       of the mouth                                               and tongue,
short observation     period                         reported   in the paper,    the type of                                         and an 8-month     history   of spasmodic        chest                                            movements.
planning   Dr. Glickman’s                           concept    would require.                                                        At age 5 1 she developed         severe     depressive                                              symptom-
    We        thought            other    solutions           were    more      important   for pa-                                  atology    after    a vaginal       hysterectomy.            She was treated
tients        recovering             from    major          psychotic      reactions.     We ques-                                   with thiothixene,          10 mg/day,         and protniptyline,          10 mg/
tion providing      large blocks of time to recovering                                                          patients             day. The patient         continued         at the same          dosage   of pro-
without   first giving them short periods   away from                                                          hospital.             tniptybine     for 2 years       and thiothixene            for 3 years.      She
We described                    methods           to provide            short      out-of-hospital                       pen-        was not taking         medication         at the time of the examina-
ods      in our         paper.        Dr. Glickman                    apparently               did not consider                      tion. Therewas         no family      history     ofdepression,        suicide,
these    adaptive       attempts     significant.                                                                                    dementia,       or abnormal        movements.
    We disagree          with Dr. Glickman’s                                interpretation                     that our                 Examination                      revealed     that            her speech   and respiration
behavior        expressed        authoritarian,                             paternalistic                     attitudes              were interrupted                       at frequent               intervals  by spasms     of the
about     Medicaid-financed            patients                          and their        care.               Medicaid               diaphragm.    She exhibited                             a fine tremor                    of the right hand
policies  directly       affect Medicaid-financed            patients.       Govern-                                                 and left ring finger,  frequent                            licking  and                  smacking    move-
ment guidelines          dictate    the care of Medicaid            patients,      and                                               ments,          and        protrusion             of the tongue.                     She         had a tremor
changes    in the political          sphere     may dramatically           alter that                                                of both          legs    at a rate of about        four cycles        per second,
care. For example,            Medicaid      funds cannot      be used for abor-                                                      especially            when    she was sitting         or standing.        She also
tion in most of the country.             Medicaid-financed          patients     must                                                showed           infrequent       rocking   of the body         and occasional
be informed        about      the economic        conditions       affecting     their                                               titubation           of the head.       The following      laboratory       studies


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