Leonhart D: Malpractice anxiety. New. York Times, Aug 17, p 201. Available at blogs.nytimes.com/2011/08/17/malpractice- anxiety/?ref=economicscene.
LETTERS ican psychiatrists. We must work to understand factors that lead to career satisfaction and develop strategies to enhance the recruitment of psychiatrists. Sidney Weissman, M.D. Dr. Weissman is professor of clinical psychiatry at the Feinberg School of Medicine, Northwestern University, Chicago.
References 1. DeMello JP, Deshpande SP: Career satisfaction of psychiatrists. Psychiatric Services 62:1013–1018, 2011 2. Leonhart D: Malpractice anxiety. New York Times, Aug 17, p 201. Available at blogs.nytimes.com/2011/08/17/malpracticeanxiety/?ref=economicscene
In Reply: We thank Dr. Weissman for his comments on our article. He raises some interesting issues, and we appreciate the opportunity to address them. The first concern raised by Dr. Weissman is in regard to the absence of information about the representativeness of the sample. Our study is based on data collected by the Center for Studying Health System Change in its 2008 Health Tracking Physician Survey (www.hschange.org/CONTENT/1085/1085.pdf). The survey is based on a classical stratified design with proportional allocation. The weighted response rate for specialists, which includes psychiatrists, was 61.9%. Unfortunately, no details are provided regarding the total number of surveys sent to physicians within each specialty. Dr. Weissman singled out the statement that older psychiatrists cannot afford to retire. We feel that our statement has been taken out of context. In fact, the article states, “However, in terms of decision to retire, one major factor that is not dealt with in the study is the financial aspirations and overall financial situation for the physician. It is very likely that many psychiatrists of retirement age continue to work because they cannot afford to retire.” Note that this statement is merely a conjecture on our part and is not an issue that was examined in our analyses. It does, how1234
ever, present an interesting topic for future research. Dr. Weissman’s speculation that the shorter work schedule of younger physicians (including psychiatrists) is offset by the extended workload of new psychiatrists who engage in medication management practice, while interesting, is not borne out by our findings. The shortage of psychiatrists, however, is a matter of critical concern that has been noted in various national journals, as we reported in our article. Dr. Weissman’s comments on malpractice suggest that it may not be a major issue for psychiatrists. In fact, the blog by David Leonhart cited by Dr. Weissman quotes from the New England Journal of Medicine: “Although … annual rates of paid claims are low, the annual and career risks of any malpractice claim are high, suggesting that the risk of being sued alone may create a tangible fear among physicians.” This is precisely the point our study makes. Finally, we agree with Dr. Weissman that more meaningful data are needed to assess the current career satisfaction of American psychiatrists. Jim P. DeMello, D.B.A. Satish P. Deshpande, Ph.D.
fully accountable. (The fifth category is slightly diminished accountability, and no defendants were judged to have this level of accountability.) Most of the suspects did not have a violent criminal past and were not under psychiatric treatment at the time of the offense, in line with the findings of Dr. Nielssen and colleagues. In conclusion, the rate of violent offenses among persons with psychosis is even higher than the number of persons found NGMI. For example, some psychotic defendants commit a homicide because they need money to support a comorbid addiction. Although not all violent offenses by persons with psychosis are caused by the underlying psychosis, we fully agree with the authors that the early recognition and treatment of psychosis may prevent violent offences. David Vinkers, M.D., Ph.D. Marieke Liem, M.A., Ph.D.
Psychosis and Homicide
2. Vinkers DJ, de Beurs E, Barendregt M, et al: Pre-trial psychiatric evaluations and ethnicity in the Netherlands. International Journal of Law and Psychiatry 33:192–196, 2010
To the Editor: We read the article by Dr. Nielssen and colleagues (1) in the July issue with interest. The authors’ analysis indicated that 138 persons with psychosis were found not guilty of homicide on the grounds of mental illness (NGMI). In a large database of 21,857 Dutch pretrial psychiatric reports made between 2000 and 2006, we found that 61 homicides were committed by people with a psychotic illness (2). Unlike other Western countries, the Netherlands applies a 5-point scale of accountability (3). Of the 61 reports that we investigated, 36 psychotic defendants (59 %) were considered unaccountable, 14 (23%) had strongly diminished accountability, four (7 %) had diminished accountability, and one (2%) was considered PSYCHIATRIC SERVICES
Dr. Vinkers is a psychiatrist at the Netherlands Institute of Forensic Psychiatry and Psychology. Dr. Liem is assistant professor of criminology at University of Leiden, the Netherlands.
References 1. Nielssen OB, Yee NL, Millard MM, et al: Comparison of first-episode and previously treated persons with psychosis found NGMI for a violent offense. Psychiatric Services 62:759–764, 2011
3. Vinkers DJ, de Beurs E, Barendregt M, et al: The relationship between mental disorders and different types of crime. Criminal Behaviour and Mental Disease, July 2011. DOI 10.1002/cbm.819
In Reply: Dr. Vinkers and Dr. Liem make an important point about the difference between the number of patients with psychotic illness found NGMI and the total number of people with psychotic illness who commit serious violent offenses. In New South Wales the proportion of homicide offenders with psychosis found NGMI was far higher than the proportion of people with psychosis charged with severe nonlethal violent
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