Search

Psychiatrists and other psychotherapists are not generally required to provide Miranda-like warnings to their patients. Even so, many psychotherapists issue such warnings before encountering clinical situations that frequently arise in general clinical practice and have potential involvement with the legal system. Ethical considerations of whether to utilize Miranda-like warnings in common clinical situations such as involuntary hospitalization, the duty to warn and protect, and suspected child abuse reporting, are explored.

One hundred eleven mildly to moderately insomniac patients participated in a double-blind, placebo-controlled study to establish the efficacy of diphenhydramine as an over-the-counter (OTC) sleep aid. A two-week crossover design was employed in which all patients received both diphenhydramine and placebo for one week each. The daily diphenhydramine dose was 50 mg at bedtime. Results obtained indicate that diphenhydramine improved various sleep parameters, including sleep latency, to a significantly higher degree than did placebo. In addition, patients on diphenhydramine reported feeling more restful the following morning and patients preferred the diphenhydramine drug to placebo despite experiencing more side effects. This study thus supports the use of 50 mg diphenhydramine as an OTC sleep aid in the treatment of temporary mild to moderate insomnia.

Legal constraints upon therapeutic flexibility, resulting in breaches of confidentiality, can promote counterproductive effects upon patients and society. Conflicts can be created for mental health professionals who sometimes must choose between maximum self-protection and doing what they believe is ethical. A survey of forensic psychiatrists indicated that most believe they face ethical problems created by some ambiguities in current reporting statutes if they are interpreted to mandate reporting and warning. Emphasis is given: (1) to the ethical choice faced by therapists as to whether rigidly to report and warn to limit liability in all Tarasoff-type situations and in some ambiguous child abuse situations, or to take an alternative action when it is clinically indicated for the benefit of a patient and/or society; (2) to the importance of understanding the distinction between potential criminal liability for failure to report under many child abuse laws, and the risk only of civil liability in Tarasoff-type cases; and (3) to appreciate the flexibility permitted by current "Tarasoff" laws. Our case histories demonstrate that mandated erosion of therapeutic confidentiality can present serious problems for patients and others. Suggestions are included for modifications in the current reporting statutes, focusing on the perspective that clinical flexibility is an essential adjunct to community protection as well as to effective therapy.

The anxiolytic effects of clobazam, diazepam, and placebo were compared in a 4-wk double-blind study of 159 anxious outpatients, primarily from family practice. Clobazam (30 to 80 mg/day) and diazepam (15 to 40 mg/day) were found to induce similar side effect, primarily sedation, and although both active drugs induced greater clinical improvement than placebo, clobazam induced the largest degree of improvement in most aspects. It was speculated that the relatively high daily dosage of diazepam may have been contributed to these results.