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-
‘ 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
‘ 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