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Stalking Intrusive Behaviors and Related Phenomena by Patients
The doctor-patient relationship should ideally be a collaborative and mutually respectful one. In some instances, however, patients may engage in behaviors that can engender concern and even fear in the psychiatrist involved. When these behaviors are repeated, unwanted, and distressing, we might colloquially refer to them as “stalking.” In the midst of a stalking episode, it may be difficult for the psychiatrist to know how to proceed, what steps to consider to protect oneself and what choices to consider to manage the patient-physician relationship. In this document we provide practical guidance for psychiatrists who may face these situations in the course of their work with patients. It was drafted via the consensus of individuals whose practices intersect at the interface of law and psychiatry and represents a range of voices and recommendations. It provides general guidance and is not considered dispositive for any particular response to specific situations. Individual circumstances may require courses of action that differ from those noted in this document.
Across State Line Psychiatric Consultation Considerations Addendum to Risk
In 2013, an APA Resource Document on “Risk Management and Liability Issues in Integrated Care Models” was developed.1 This document outlined liability issues in a new and emerging area of collaborative /integrated care. In this model psychiatrists’ expertise is leveraged through curbside consultations and caseload reviews to provide more effective care for mild to moderate behavioral health conditions in the primary care setting. With the advent of CPT codes for the Collaborative Care Model, there has been a noticeable increase in the number of requests psychiatrists are receiving to do indirect consultations, caseload reviews, and education in states where they are not licensed. Further, the use of telecommunication solutions to enhance and expand existing services in one state can lead to increases in requests for psychiatric consultation to address patient choice, peer consultation, and workforce shortages in another state. States are actively developing policies to address the issue of licensure requirements for these consultation services, including physician to physician (P2P) consultation
Decisional Capacity Determinations in Consultation-Liaison Psychiatry: A Guide for the General Psychiatrist
Consultation-Liaison Psychiatrists are experienced in responding to requests from medical services for the determination of decisional capacity (DC). General psychiatrists are occasionally called upon to perform decisional capacity determinations, especially when functioning in a consultation-liaison role. Some may not have extensive prior or current experience in decisional capacity determinations. In recent years, there has been a significant amount of clinical research literature on DC, particularly in a consultation-liaison clinical context. As such, having a review of the recent literature leading to an evidence-based, standardized approach to DC determinations is of pragmatic value to the general psychiatrist.
Reclassification of ECT Devices
On December 26, 2018, the Food and Drug Administration (FDA) issued a final order regarding the reclassification of devices for administration of electroconvulsive therapy (ECT).i On the basis of device risk and the steps needed to give reasonable assurance of safety and effectiveness, the FDA categorizes medical devices into one of three classes (Class I, II, or III), with Class I devices generally posing the lowest risk to the patient.ii As part of a broader statutory requirement to re-categorize class III devices that were marketed prior to May 28, 1976,iii the FDA evaluated evidence related to the effectiveness and safety of ECT, convened a meeting of its Neurological Devices Advisory Panel to evaluate the effectiveness and safety of ECT devices, published a draft order on the reclassification of ECT devices and reviewed over 3,400 public comments related to the draft order. The American Psychiatric Association (APA) participated in this process by providing testimony at the Neurological Devices panel hearing and by submitting detailed comments on the draft order.i
Psychiatric Aspects of Infertility
The psychological impact of being unable to conceive despite trying is a profound loss and a significant life crisis (Kohan et al. 2015). Many individuals suffer in isolation, unaware that infertility is highly prevalent afflicting approximately one in eight couples worldwide. The feelings and reactions to infertility are complex, ranging from anger with self for the failure of one’s body to procreate (Kohan et al. 2015), an associated decrease in sexual desire, an impaired orgasmic function and a loss of sexual satisfaction when ‘sex by the clock for procreation’ is required (Kohan et al. 2015; Marci et al. 2012). Couples may feel socially excluded, negatively stigmatized (Ergin et al. 2018) and find it particularly painful to be around other couples with children or with unaware extended family members who make insensitive comments. Women trying to conceive face profound sadness and grief with each returning menstrual cycle. Seeking treatment with an infertility healthcare provider requires significant sacrifice of time, privacy and money with no guarantee of conception or successful birth. This can be disempowering, stressful, frustrating, and at times profoundly sad.
Opposition to the Use of Cannabis for PTSD
The use of cannabis for medical indications has received considerable attention as several states have moved to legalize cannabis for various purposes. A growing number of patients cite post-traumatic stress disorder (PTSD) as the reason for seeking cannabis for medical purposes in states where it is legal.1 Furthermore, approximately 15% of Veterans who are treated in Department of Veterans Affairs (VA) outpatient PTSD clinics report recent (past 6 months) cannabis use.2 This position statement was developed through review of the evidence to date and to establish the APA's consensus on the matter.
Assessment and Treatment of Gender Dysphoria and Gender Variant Patients
Regardless of their area of specialization, adult psychiatrists are likely to encounter patients who are transgender; however, medical school curricula and psychiatric residency training devote little attention to caring for these patients. The primary aim of the present article is to assist adult psychiatrists who do not specialize in transgender clinical care in the delivery of respectful, clinically competent and culturally attuned care to gender variant patients including those who identify as transgender or transsexual or meet DSM-5 criteria for the diagnosis of Gender Dysphoria. The following are reviewed: The history and evolution of conceptualizations of gender variance, its classification and related terminology including differences between DSM-IV and DSM-5; the prevalence of transgender identity and Gender Dysphoria; the influences of biological and psychosocial factors on gender development; the clinical assessment and treatment of Gender Dysphoria in adults; and current societal trends, including increased societal acceptance of gender variance, legal protections for gender variant individuals and increased access to gender transition services.
Opposition to Cannabis as Medicine
The medical use of cannabis has received considerable attention as several states have voted to remove civil and criminal penalties for patients with qualifying conditions. Yet, on a national level, cannabis remains a schedule I substance under the Controlled Substances Act (CSA), the most restrictive schedule enforced by the Drug Enforcement Administration (DEA) (1). The Food and Drug Administration (FDA), responsible for approving treatments after appropriate and rigorous study, has not approved cannabis as a safe and effective drug for any indication (2). This juxtaposition of practice and policy has prompted many professional medical organizations to issue official positions on the topic. This statement reflects the position of the American Psychiatric Association (APA) on the use of cannabis for medical and psychiatric indications, taking into account the current evidence base and statements from other medical organizations. It does not cover the use of synthetic cannabis-derived medications such as Marinol and Syndros (dronabinol), Cesamet (nabilone) or Epidiolex (contains a purified drug substance cannabidiol, one of more than 80 active chemicals in cannabis) which have been studied and approved by the FDA for specific indications.
Neuroimaging
The application of neuroimaging technology in psychiatric research has revolutionized clinical neuroscience perspectives on the pathophysiology of the major psychiatric disorders. Research using a variety of types of neuroimaging techniques has shown that these conditions are associated with abnormalities of brain function, structure and receptor pharmacology. These data also corroborate the conclusions reached from genetic, endocrine, and clinical pharmacology research involving these disorders to suggest that under the current nosology the major psychiatric disorders likely reflect heterogenous groups of disorders with respect to pathophysiology and etiology. Despite the invaluable leads that the neuroimaging studies have provided regarding the neurobiological bases for psychiatric disorders, they have yet to impact significantly the diagnosis or treatment of individual patients.
Physician Health Programs in the Treatment of Substance Use Disorders in Physicians
In 1974, the American Medical Association (AMA) acknowledged physician impairment from alcoholism and drug dependence occurs, and recognized alcoholism and addiction as illnesses. Physician illness and impairment exist on a continuum with illness typically predating impairment, often by many years. This is a critically important distinction. Illness is the existence of a disease. Impairment is a functional classification and implies the inability of the person affected by disease to perform specific activities.
QTc Prolongation and Psychotropic Medications
Psychiatrists and other clinicians frequently prescribe psychotropic drugs that may prolong cardiac repolarization, thereby increasing the risk for torsades de pointes (TdP). The corrected QT interval (QTc) is the most widely used and accepted marker of TdP risk. This resource document was created in response to the paucity of strong evidence to guide clinicians in best practice prescription and monitoring of psychotropic medications that may increase risk of TdP.
Advocacy Teaching in Psychiatry Residency Training Programs
Advocacy, generically defined as the active support for a particular cause, policy, or issue, is applicable to medicine and psychiatry as physicians’ responsible use of “their expertise and influence to advance the health and well-being of individual patients, communities, and populations” (Frank, 2005). Advocacy can be undertaken from within an organization or as an outside stakeholder, and it can focus on a single theme (e.g., Barber, 2008) or more generally on issues that relate to patient needs, including the social determinants of health (e.g., Chin, 2017). Although the concept of advocacy is commonly linked to legislative advocacy, a specific arena of advocacy that seeks to influence policy and politics, it is also applicable more broadly to other activities that physicians undertake to support specific causes (e.g., community-level advocacy to avert the shutdown of a homeless shelter, interviews with the lay media as advocacy to inform public opinion).