No abstract

Discussing medical treatment options and risks becomes a more complicated task when patients have psychiatric problems. Such patients may perceive risk and judge options differently from usual, they raise special issues about informed consent and competency, and they may present special needs and stresses in the physician-patient relationship. This article addresses how to approach such treatment discussions within the framework of 3 content areas of the medical interview (medical decision making, informed consent, and the physician-patient relationship) and 2 formal techniques of the interview (exploration and assertion). Clinical research regarding how psychiatric problems may affect each of these areas of concern is reviewed. Ultimately, the goal of understanding such variations--and of possessing methods to address them in discussing treatment options and risks--is to help the patient be as free as possible from the burden of biases or distortions in making his or her decisions and to promote the best fit between the patient's wishes and the physician's medical judgment.

Denial is a psychological defense in which the individual repudiates some or all of the meanings of an illness, thereby warding off an awareness of painful thoughts and feelings such as fear, grief, depression, and anger. Although it is often viewed as a problem, denial may at times be a healthy and adaptive response to illness. In the medical interview, denial may be exhibited by the patient, the physician, or both. Not all instances of denial can or should be addressed within the interview. The decision to address denial can be made based on how adaptive the denial is, what kind of psychosocial support is available to the patient, and how well prepared the patient is to deal with the fears that underlie denial. In those instances when denial should be addressed, the interviewer can use techniques of clarification, confrontation, and interpretation.

Although clinical experience suggests that individuals who have been bereaved as a result of suicide may be especially vulnerable to adverse sequelae, such as unusually severe grief or increased risk of committing suicide themselves, the idea that this type of bereavement is special has received only limited systematic investigation. The authors review the literature on the subject, with special attention to the clinical and research evidence about whether bereavement resulting from suicide is different from bereavement due to other types of death, and make suggestions for further clinical and epidemiological research on this question.