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IMMUNOSUPPRESSANTS FOR TREATMENT OF RA (RHEUMATOID ARTHRITIS): METHOTREXATERheumatrexTablet size: 2.5 mgUsual dose: two to six pills all on one day per week or in one weekly injection Effective within: three to eight weeksMethotrexate was used initially in the 1940s to treat people with leukemia and is still frequently taken in very high doses as an anticancer drug. It later became widely used as treatment for severe psoriasis and a form of arthritis associated with this skin condition. Since the early 1980s its use in the treatment of RA has skyrocketed.The marked increase in this drug’s popularity for RA treatment has many explanations. First, it becomes effective more rapidly than the other DMARDs: improvement is sometimes noted within two weeks of the first use. Second, it is possibly the most effective medication available. It is as effective as injectable gold or penicillamine, previously believed to be the most effective pharmaceutical treatment for RA. Third, it is very convenient in that it can be taken once a week if tolerated.*96/209/5*

PSYCHIATRIC DIMENSIONS OF MEDICAL PRACTICE: COMPETENCE TO REFUSE MEDICAL ADVICE-WHEN THE EXAMINER IS UNCERTAIN: INVOLVING FAMILY MEMBERSIt is not uncommon for physicians to evaluate the competence of patients they have never met before. As in the case described above, family members can be helpful when the outcome of the evaluation is equivocal. Based on his sister’s report, Mr. B.’s reluctance to follow medical advice did not spring from a delusional belief that God would heal him. The patient’s decision-making capacity was intact, though he was understandably apprehensive about a lung biopsy and responded with characteristic irritability and obstinacy when repeatedly urged to have one.     Family members are almost always willing to compare a patient’s current way of thinking with what they have observed in the past. They cannot be asked to decide whether or not the patient is competent, but they can be asked to decide whether or not he is himself.*73\172\2*

PSYCHIATRIC DIMENSIONS OF MEDICAL PRACTICE: COMPETENCE TO REFUSE MEDICAL ADVICE-INVOKING THE LAW: INVOLVING PSYCHIATRIC CONSULTANTSPsychiatric consultation is usually indicated when patients are found incompetent to refuse medical advice. Many of these patients have psychiatric disorders for which diagnosis and treatment are needed. In some cases, the disorder can be reversed and competence restored. Even when the patient’s cognitive deficit is permanent (as in Alzheimer disease), it is often possible to treat emotional and behavioral problems that hinder care. A certain number of incompetent patients have neither a psychiatric disorder nor emotional or behavioral difficulties. When, for example, someone who is mentally subnormal or stuporous refuses medical advice, consultation is usually unnecessary.     Although patients who are incompetent often have psychiatric disorders, patients with psychiatric disorders are seldom incompetent. Decision-making capacity in psychiatric patients should be assessed in the usual way. When they refuse medical advice and are competent to do so, their reasons are likely to be the same as those given by nonpsychiatric patients.     Psychiatric consultation is sometimes helpful when surrogate decision makers disagree about what to do and the patient’s physician cannot resolve the dispute. Here again, the psychiatrist may be called as an advocate but function as a mediator.*71\172\2*