General Therapeutic Indications: Institution-Commitment - Treatment Of Excitement, Suicidal Tendencies, And Refusal Of Food-Psychotherapy - Parole And Discharge - Aftercare.

There is no general treatment for all mental affections any more than there is for all affections of the stomach or kidneys. Certain therapeutic indications, however, are of such importance and arise so often that it will be advisable to make a general study of them.

Some pertain to the surroundings in which patients should be placed, others to certain particularly grave manifestations: excitement, suicidal tendencies, and refusal of food.

Surroundings; Institution; Commitment

In most psychoses it is necessary to secure for the patient physical and mental rest and to relieve him as far as possible from his preoccupations, delusional or rational.

It is difficult to carry out these indications in the ordinary conditions of life. The difficulties are of a nature both physical and mental; physical, because only few families can afford the expense involved in the treatment of a psychotic patient at home; and mental, because the relatives, inexperienced in the treatment of mental diseases, are not likely to carry out properly all the orders of the physician, and may cause an aggravation of the patient's condition by yielding to his caprices, being under the impression that he must not be contradicted, and by wearying him with attempts to reason with him or to divert his mind.

The removal to an institution is therefore in most cases inevitable.

All psychotic patients may be grouped in two classes: the inoffensive and the dangerous.

For the first class of cases the institution does not present any particular features and the admission of the patient is effected with no more formality than that into a general hospital.

The patients of the second class must be committed; this must be accomplished under the supervision and responsibility of a public authority, and entails certain formalities.

Of all these formalities only one is of interest to us here: the physician's certificate.

The certificate, intended to establish the legitimacy of the commitment, need not contain any detailed observations and does not necessarily involve a precise clinical diagnosis. It is of little importance here whether the patient does or does not present inequality of the pupils or abolition of the patellar reflexes. It is also unimportant whether he suffers from mania or from dementia praecox, as long as the symptoms which he presents render him a menace to himself, to others, or to the public peace.

The indications for commitment are chiefly to be based on the dangerous tendencies of the patient; a senile dement who is quiet and tractable can without any inconvenience be cared for at home or in a home for the aged; another who is on the contrary irritable and violent should be committed without hesitation.

In a general way the following symptoms should be considered as indications for commitment: impulsive tendencies; suicidal ideas, ideas of persecution and hallucinations which bring about violent reactions; states of dementia associated with phenomena of excitement.

The character and intensity of the symptoms should, however, not be the only factors governing the action of the physician. He should also take into account their probable duration. If the mental disorder is not likely to persist for more than several days and has no tendency to recur frequently, commitment is not justifiable; such is the case in febrile deliria.

Transfer Of The Patient To The Institution

Undoubtedly it is the physician's duty to induce the patient to go to a hospital. Unfortunately this is not always easy or even possible when the question is one of commitment. This question, at times delicate, cannot of course have a universal solution.