In case you missed this archived case report from Leentjens AFG, et al. Manipulation of mental competence: an ethical problem in case of electrical stimulation of the subthalamic nucleus for severe Parkinson’s disease. Ned Tijdschr Geneeskd. 2004 Jul 10;148(28):1394-8. Assuming you speak fluent Dutch.

A patient with severe Parkinson’s disease failed traditional treatments. He was bedridden, captive to a serious movement disorder. As a last resort, his physicians inserted electrodes in his subthalamic nuclei and initiated deep brain stimulation.

Three years later, he was admitted to a facility to address stimulation manic episode. This behavior did not respond to mood stabilization agents. He experienced “chaotic behavior, megalomania, serious financial debts, and mental incompetence.” The symptoms are not dissimilar to reports of hypomanic or even manic behavior from dopamine D2 and D3 agonists, such as ropinirole. From the American Journal of Psychiatry:

In clinical trials, the dopamine agonist ropinirole has produced hallucinations and confusion rated as mild. We provide evidence here that ropinirole may induce or exacerbate severe, acute psychosis in a patient without Parkinson’s disease. This case is not conclusive in part because of the use of quetiapine. However, the rapidity and degree of improvement weigh in favor of a strong role for ropinirole, and the likelihood of such an effect with this medication stands to reason. Given the recognized relationship of dopaminergic function to psychosis, best known through the strong antipsychotic effects of dopamine antagonists, such an effect of exacerbating psychosis by a dopamine agonist seems almost predictable. We suggest that ropinirole, like all other dopaminergic agents, be used with caution in psychotic patients and those vulnerable to psychosis.

In managing dopamine agonist psychosis or mania, changing the dose of the medication may mitigate the effects. Adding an anti-psychotic agent may also soften the suboptimal outcome.

In the case report, there was no therapeutic margin between the two states – (a) alleviation of Parkinson’s symptoms but associated with mania and/or psychosis, versus (b) normophoric state with return of capacity of judgment and insight, but with significant exacerbation of motor symptoms, leaving him bedridden.

The question was which of these two states was preferable. To the patient, there was no middle ground.

The patient’s doctors concluded that only with the stimulator turned off was the patient competent to make an informed decision. Meaning, his doctors posed the question of preference with the stimulator off; in the normophoric, bedridden state.

The patient’s verdict –  he preferred to be admitted to a psychiatric ward in a chronic manic state. There, he’d have acceptable motor function and reasonable activities of daily living. He shunned the option of normal cognitive / mood function at the expense of being bedridden.

Mental competence and informed consent can be affected by our treatments. If treatment is clouding judgment, the patient as a participant in his decision-making should be afforded the opportunity to have that cloud lifted, even if his final decision is to let the cloud return.

The patient in this case lived in and was treated in the Netherlands. It’s possible that the process and outcome in the United States would have been different.

What do you think?

Medical Justice provides free consultations to doctors facing medico-legal obstacles. We have solutions for doctor-patient conflicts, unwarranted demands for refunds, online defamation (patient review mischief), meritless litigation, and a gazillion other issues. If you are navigating a medico-legal obstacle, visit our booking page to schedule a free consultation – or use the tool shared below.

Jeffrey Segal, MD, JD

Chief Executive Officer and Founder

Dr. Jeffrey Segal, Chief Executive Officer and Founder of Medical Justice, is a board-certified neurosurgeon. Dr. Segal is a Fellow of the American College of Surgeons; the American College of Legal Medicine; and the American Association of Neurological Surgeons. He is also a member of the North American Spine Society. In the process of conceiving, funding, developing, and growing Medical Justice, Dr. Segal has established himself as one of the country’s leading authorities on medical malpractice issues, counterclaims, and internet-based assaults on reputation.

Dr. Segal was a practicing neurosurgeon for approximately ten years, during which time he also played an active role as a participant on various state-sanctioned medical review panels designed to decrease the incidence of meritless medical malpractice cases.

Dr. Segal holds a M.D. from Baylor College of Medicine, where he also completed a neurosurgical residency. Dr. Segal served as a Spinal Surgery Fellow at The University of South Florida Medical School. He is a member of Phi Beta Kappa as well as the AOA Medical Honor Society. Dr. Segal received his B.A. from the University of Texas and graduated with a J.D. from Concord Law School with highest honors.

In 2000, he co-founded and served as CEO of DarPharma, Inc, a biotechnology company in Chapel Hill, NC, focused on the discovery and development of first-of-class pharmaceuticals for neuropsychiatric disorders.

Dr. Segal is also a partner at Byrd Adatto, a national business and health care law firm. Byrd Adatto was selected as a Best Law Firm in the 2023 edition of the “Best Law Firms” list by U.S. News – Best Lawyers. With over 50 combined years of experience in serving doctors, dentists, and other providers, Byrd Adatto has a national pedigree to address most legal issues that arise in the business and practice of medicine.