Psychiatric Association Research Articles

Psychiatrists Go Beyond Call of Duty to Respond to Harvey’s Victims

Psychiatrists Go Beyond Call of Duty to Respond to Harvey’s Victims

Neurological and psychiatric associations in bullous pemphigoid-more than skin deep?

In elderly patients, bullous pemphigoid (BP) is associated with several comorbidities; the strongest association occurs between BP and neurological diseases. Different types of dementia, Parkinson's disease, cerebrovascular disorders and epilepsy all have a significant association with BP, but patients with multiple sclerosis have the highest risk of BP. An existing neurological disorder appears to increase the risk for subsequent BP, but an increased risk for developing some neurological diseases has also been reported following BP diagnosis. BP seems to be associated with several psychiatric diseases such as schizophrenia, uni- and bipolar disorder, schizotypal and delusional disorders, and personality disorders, but the risk ratios are usually lower than with neurological diseases. In addition to the skin, the BP autoantigens BP180 and BP230 are expressed in the central nervous system. This finding together with the strong epidemiological association between neurological disorders and BP has led to an assumption that neurodegeneration or neuroinflammation could lead to a cross-reactive immunoresponse between neural and cutaneous antigens and the failure of self-tolerance. A subpopulation of patients with Alzheimer's disease or Parkinson's disease have circulating IgG autoantibodies against BP180, but currently their significance for the development of BP is unclear, because these antineural BP180 antibodies neither bind to the cutaneous basement membrane nor cause BP-like symptoms. Further studies analysing large and well-characterized populations of neurological and psychiatric patients are required to understand better the role of autoimmunization against neural BP autoantigens in the pathogenesis of BP.

Psychiatrists Cross Borders for Collaborative Learning

Back to table of contents Previous article Next article International NewsFull AccessPsychiatrists Cross Borders for Collaborative LearningAaron LevinAaron LevinSearch for more papers by this authorPublished Online:29 Aug 2017https://doi.org/10.1176/appi.pn.2017.8a1AbstractSharing knowledge and developing collegial friendships know no boundaries.Some people want to build walls along the border between the United States and Mexico, while other people want to build bridges and roads to link them closer together.Transnational cooperation was evident at a joint conference convened by Mexican and U.S. psychiatric associations and held on both sides of the border.A few weeks after APA’s 2017 Annual Meeting in San Diego, members of the San Diego Psychiatric Society met with their counterparts from Mexico. Sessions were held in both San Diego and Tijuana, just a short drive away. The theme was “Psychiatry Without Borders” and featured presenters from both Mexico and the United States, said Bernardo Ng, M.D., chair of APA’s Council on International Psychiatry and vice president of La Asociación Psiquiátrica Mexicana (APM). Former APA President Michelle Riba, M.D., of the University of Michigan, offered the opening remarks in Tijuana, while Enrique Chavez, M.D., the president of the APM, closed the event with a talk in San Diego.The collaborative meeting was conceived by Ng, who practices at Sun Valley Behavioral Health in Imperial, Calif., about 100 miles east of San Diego, near the Mexican border, and Steve Koh, M.D., M.P.H., M.B.A., a professor at the University of California, San Diego, and former president of the San Diego Psychiatric Society. One benefit of the program: all attendees could receive CME credits from their respective societies.“For the first time, we had a meeting that was held concurrently in English and Spanish, where psychiatrists and researchers from both countries attended and presented lectures and symposia,” said Ng.For instance, a symposium on neuromodulation was presented by two experts on ECT, Maria Lapid, M.D., of the Mayo Clinic and Sergio Galvan, M.D., of Mexico’s Hospital Angeles. The segment on transcranial magnetic stimulation was delivered by Simon Kung, M.D., of Mayo and two psychiatrists from the Clinic STIM in Guadalajara, Mexico, Thelma Sanchez, M.D., and Marisela Duran, M.D. A symposium on eating disorders matched Walter Kaye, M.D., of the University of California, San Diego, with Eva Trujillo, M.D., of Volver a Empezar in Mexico. “We are also trying to coordinate training opportunities between U.S. and Mexican institutions to permit rotations in both directions,” said Ng.Drugs—legal and illegal—present questions for both psychiatric societies. Americans often head south to buy drugs, including antipsychotics, which are available in Mexico without prescription. That raises questions about monitoring patients once they return home, said Riba. Meanwhile, the passage of medical marijuana laws in California has resulted in increased smuggling of the weed into Mexico, a reversal of the historical norm, said Ng.The border region extends about 25 miles on either side of the formal boundary and has a very mixed culture, said Ng. The area is so used to free exchange of visitors that it has more in common within the region than with the rest of each country.“If people move elsewhere, it’s like they’re going to another country,” said Ng. “I get one new patient a month who is a college student returning home with psychosis or depression because of culture shock.”Even in a moment of political distancing, he said, commerce, collaboration, and scientific exchange will continue, he said. “We were able to do real-time comparisons in both countries, and we found that there were more similarities than differences. This connection is not going to stop.” ■ ISSUES NewArchived

Psychologist Prescribing Bills Defeated in Many States

Back to table of contents Previous article Next article Professional NewsFull AccessPsychologist Prescribing Bills Defeated in Many StatesAaron LevinAaron LevinSearch for more papers by this authorPublished Online:27 Jul 2017https://doi.org/10.1176/appi.pn.2017.8a2AbstractArguments against psychologist prescribing legislation go beyond opposition to include expanded access to care for the underserved.APA members in state psychiatric societies, working with staff of APA’s Department of Government Relations, have beat back a number of bills this year that would have allowed psychologists to prescribe medications. And although a bill was passed in Idaho, it mandates what many APA members strongly fought for—very stringent standards of training for psychologists who seek prescribing privileges. Evidence from New Mexico and Louisiana, which have had prescribing laws on the books since 2002 and 2004, respectively, show little, if any, expansion of access to mental health care in rural or other underserved areas, one of the main arguments of psychologists who favor prescribing. “As physicians, we will continue to fight to protect our patients,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “We will also continue to provide support to district branches in educating legislators about the importance of advocating for people with mental illnesses and substance use disorders and ensuring that the care they receive is medically based.”Advocacy activity at the state level is aimed at patient safety; prescribing is not a right, it is a privilege earned after stringent education requirements are met. That means not just short courses or online training but medically based classes in biology, chemistry, biochemistry, physiology, and other science-based courses and clinical experience necessary to understand the human body, its interaction with medication and comorbid illness. Because of the potent advocacy activity in state capitols, bills have been slowed or their introduction deferred in Florida, Kentucky, Minnesota, New Jersey, New York, North Dakota, Ohio, Texas, and Vermont, among others, said Amanda Blecha, J.D., APA’s Midwest regional field director for state government affairs, in an interview. “The Nebraska Psychiatric Society is leading the effort to oppose the psychologist prescribing application through the credentialing process, in hopes that the technical review committee will not recommend it to the state legislature in advance of 2018.”APA’s district branches and state associations are working hard to educate lawmakers and the public that there are existing options to increasing access to care, added Blecha. “We also promote evidence-based alternatives in many states to mental health access challenges, like expansion of collaborative care models, telepsychiatry implementation, improving network adequacy, and parity enforcement. Collaborative care, for example, leverages the relative scarcity of psychiatrists by having them provide consultations to primary care physicians. Collaborative care allows up to 20 patient cases to be handled by a psychiatrist in a morning as opposed to traditionally four.”Advocacy efforts have also been stepped up in the battle against opioid addiction and overdoses, which now is taking up much legislative attention on the state level, said Angela Gochenaur, M.P.A., APA’s Northeast regional field director.“We argue that if legislators are putting new restrictions on prescribing practices, why add yet more prescribers with even less experience?” said Gochenaur. Furthermore, important medications (such as naloxone) used to treat substance use disorders can be dispensed only by specially trained and certified physicians, which would rule out a role for psychologists, in any case, she said. ■ ISSUES NewArchived

When Being Human Is a Boundary Crossing

Back to table of contents Previous article Next article Ethics CornerFull AccessWhen Being Human Is a Boundary CrossingClaire Zilber, M.D.Claire ZilberSearch for more papers by this author, M.D.Published Online:19 May 2017https://doi.org/10.1176/appi.pn.2017.5b27“Many people are so overwhelmed by the intensity and intimacy of the therapeutic relationship that they experience an otherwise inconsequential gesture or statement as a full-fledged romance or romantic intrusion.” —O.B. Caudill, quoted by Thomas Gutheil and Archie Brodsky, Preventing Boundary Violations in Clinical PracticeAfter a busy day in the office, a psychiatrist goes home to have dinner with her family. At 8 p.m., when the kids are settled into doing their homework, she returns a call from a patient from earlier in the day. To the doctor, this is merely an issue of time management. For the patient, it could seem like unusual behavior and be interpreted as a sign that the patient is either very special or very troublesome to the doctor. Rising from her chair at the end of a session, a patient stumbles and loses her balance. The psychiatrist reflexively catches the patient’s elbow to steady her and leads her to the door with this support. This chivalrous gesture could leave the patient feeling either grateful to the doctor, romantically aroused, or intruded upon, depending on the patient. Like many subtle boundary crossings, these examples demonstrate ways in which a psychiatrist may view his or her behavior as innocuous or helpful while a patient might perceive it as confusing, frightening, unwanted, or seductive. The psychiatrist may remain oblivious to the effect of his or her behavior unless the patient is brave enough to discuss what happened, which temporarily shifts to the patient the responsibility for managing the therapeutic relationship, a function ordinarily assumed by the psychiatrist. Left unaddressed, the tension from these rifts in the therapeutic relationship occasionally lead patients to initiate a complaint to an ethics committee or a licensing board. A single hug initiated by a psychiatrist in celebration of a patient’s achievement, an exchange of a photograph of the psychiatrist so the patient can have a transitional object, or frequent phone contact outside of regularly scheduled sessions, while potentially therapeutic, can at times be perceived by the patient—and regulatory authorities—as inappropriate. How might a psychiatrist behave in the fairly human ways in the above illustrations while fulfilling the expectation that his or her behavior not disrupt the treatment? Any time a psychiatrist’s behavior varies from its usual course, the psychiatrist should consider discussing it. As is often stated in residency training, “It’s not what you say (or do), it’s what you say (or do) next.” It may be useful to run through the following steps each time professional behavior falls outside the norm.Reflect on what happened. How was this behavior different from the usual? Is there something about this particular patient that elicited unusual behavior? Is there something going on in the psychiatrist’s life that is shifting him or her away from standard practice? What are the ways the patient might perceive and respond to this departure from the norm? Consider consultation. If the transference or countertransference feels unusual or intense, supervision may be beneficial. If the psychiatrist is vulnerable because of a life crisis, psychotherapy may be helpful. Seeking guidance, even if it’s just for reassurance, is always a good idea. Acknowledge the boundary crossing to the patient as a way of inviting discussion. This might happen right away at the moment of the unusual behavior, such as, “I know I’m calling later than usual. I sometimes return calls in the evening so I can have dinner with my family.” Or it might happen in the next session or several sessions later if consultation is required.Apologize if the patient expresses discomfort as a result of your behavior and invite further exploration. “I’m sorry that when I grabbed your elbow, it felt patronizing to you. Are there other times when you have felt patronized by me or by others?” Psychiatrists are not automatons. It is inevitable that at times a psychiatrist’s behavior will surprise or upset a patient when it differs from expectations of how the profession behaves. Employing one’s observing ego to preempt departures from the norm when possible, reflecting on what precipitated a boundary crossing, seeking consultation, and discussing the interaction with the patient, including an apology if appropriate, allow the psychiatrist to reestablish his or her professionalism and restores equilibrium in the treatment relationship. ■Claire Zilber, M.D., is chair of the Ethics Committee of the Colorado Psychiatric Society, a corresponding member of APA’s Ethics Committee, and a private practitioner in Denver. ISSUES NewArchived

Experiences from newly created trainee associations in Spain And Macedonia

Until July 2016, Spain was not member of European Forum of Psychiatric Trainees. Why? Because Spain did never have Association of Psychiatric trainees. In July 2015, 2 Spanish trainees were invited to attend EFPT meeting in Porto. There, they connect with other European trainees and with the help of MENTA group they starting the foundation of Spanish Psychiatric Trainees Society, now known as SERP. In just 1 year, SERP has increased in number of members and have successfully developed numerous initiatives such as the establishment of our founding documents, the constitution of a democratic board through an Elective General Assembly, the design and update of a website and profiles in the social networks and the organization of the 1st Meeting for National Psychiatric Trainees, which was held in Vitoria-Gasteiz on March 2015 and had as topic Research on psychiatric training period. Last July, Spain was accepted for first time in history as full member of EFPT and we are actively participating in several working groups, even chairing the Child and Adolescent Psychiatry one. This year, Spain is also participating in international exchanges, offering two destination for European trainees. We must acknowledge that during the foundation process, the support of the Spanish National Psychiatric Associations (SEP and SEPB) and EFPT (specially its ENTA group since the first meeting of some of our now board members in the Annual Forum in Porto in 2015), has been crucial.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Implementation of EPA guidance - One way for all countries?

The European Psychiatric Association (EPA) guidance project launched in 2008 has the aim of providing European psychiatry with guidance in topics, which are relevant for European mental health care. Guidance from a European perspective can be favorable against the background of a growing sense of Europe and the desirable associated harmonization on all levels of health care policy.More precisely, the mission of the EPA guidance is defined as ‘to improve quality of mental health care in Europe by disseminating written information based on best evidence and psychiatric practice, to facilitate countries learning from each other’.In consonance with this need of a wider multinational perspective of European psychiatry, EPA adopted in 2012 through a deep change of its statutes a new membership structure that allows National Psychiatric Societies/Associations (NPAs) in Europe the possibility to become full members of EPA. Up to 40 NPAs corresponding to 37 countries and representing over 80.000 psychiatrists have responded positively to the offer and are now part of the Council of National Psychiatric Societies, the body within EPA that integrates them.The Council of NPAs has become, in this way, a forum for its members to meet, discuss and work on issues concerning European psychiatry. One of the major issues is about the implementation of European guidance in mental health policy, teaching and learning psychiatry, best clinical practice in different areas, and quality indicators. This presentation provides further details on how participating societies could put these policies and recommendations into practice.Disclosure of interestThe author has not supplied his declaration of competing interest.

An online survey of the stigma attached to psychiatry and psychiatrists in India

IntroductionStigma in psychiatry is pervasive, it does not stop at illness and marks all those who are ill, their families across generations, institutions that provide treatment, psychotropics’, and mental health professionals. Stigma directed towards psychiatry as a branch & psychiatrists in particular has not been systematically studied in the Indian context.ObjectivesTo study the Indian psychiatrists perspective of stigma directed towards psychiatry & psychiatrists.MethodsAn online survey containing “The World Psychiatric Association Stigma Questionnaire” was sent to the members of the Indian Psychiatric Society. Two hundred and three Indian psychiatrists filled out the questionnaire which assesses the stigmatization of psychiatry and psychiatrist as perceived by the psychiatrists themselves.ResultsOne hundred and thirty-two psychiatrists completed the survey with a completion rate of 65%, 75% of the respondents were male and most of their clientele was from urban catchment area. Sixty percent of the psychiatrists were either working in a psychiatry hospital or a psychiatry unit in a general hospital setting. More than a third had high-perceived stigma but had a very low stereotype agreement. Discrimination experiences were noted by more than 75% of psychiatrists, however less than 8% had a negative stigma outcome.ConclusionsThough most of the Indian psychiatrists perceive themselves as being stigmatized, the stereotype agreement was found to be low and the discrimination experiences did not have significant impact on job performance. Though this might reflect resilience, we must attempt to improve the image of psychiatry and strive towards achieving a larger public acceptance of mental health services in India.

Ethical Motivation in Terms of Developmental Stages

Back to table of contents Previous article Next article Ethics CornerFull AccessEthical Motivation in Terms of Developmental StagesClaire Zilber, M.D.Claire ZilberSearch for more papers by this author, M.D.Published Online:24 Feb 2017https://doi.org/10.1176/appi.pn.2017.3a21Much attention has been paid to ethics in the national news coverage of the recent Senate confirmation hearings. It reminds us that there is a range of ethical behavior, including concerns about conflicts of interest, dual relationships, and the establishment of boundaries. These ethical challenges are no less relevant to physicians, so a review of a psychological theory of moral development may be helpful. Lawrence Kohlberg was an American psychologist who adapted Jean Piaget’s theory of psychological development over the lifespan to address the question of moral development. He conceived a model with six stages of development according to how individuals justify their actions. The stages are subdivided into three levels: Preconventional, Conventional, and Postconventional. These levels may be used to examine the ethical developmental level of our own and others’ decisions and to identify the standards expected of physicians. The Preconventional level encompasses the first two developmental stages: Punishment and Obedience, and Instrumental Relativist. In the Punishment and Obedience stage, an action is judged morally good if it doesn’t result in punishment. Think of a young child taking another child’s toy: if he’s not punished, taking the toy must not have been wrong. In the Instrumental Relativist stage, the child learns to get what he wants through negotiation, such as a brother agreeing to share his toys with his sister in exchange for a cookie. The child is learning morally good behavior, but the motivation is egocentric: getting a cookie. This is much like a physician accepting a lavish gift from a pharmaceutical company in exchange for prescribing that company’s product. This Preconventional morality is inappropriate in medicine. The Conventional level of moral development includes the stages of Interpersonal Concordance and Law and Order. In the first of these, good actions are those that please others, resulting in a “good boy” or “good girl” affirmation. At the Law and Order level, the individual is motivated to obey the rules and respect authority. Viewed from one perspective, these may seem adequate for a well-functioning society when people are choosing actions that please others and follow the rules. However, the Law and Order level of morality has limitations: if a rule can be circumvented via a loophole or ambiguity, the individual may feel his or her actions are ethically acceptable, while others may disagree. The public should not tolerate a physician exploiting a loophole concerning professionalism. The Postconventional level of moral development involves the stages of Social Contract and Universal Ethical Principles. In the Social Contract stage, the individual is oriented toward the greater good and right action according to society’s standards. This is the motivation for people to perform altruistic behaviors, such as picking up trash they find on the ground even if they didn’t put it there. In the stage of Universal Ethical Principles, individuals are motivated by abstract principles of justice and respect for human dignity. Actions stemming from this stage include volunteering to serve in human rights organizations, participation in civil disobedience for a noble cause, or similar selfless acts designed to help others and that confer no benefit to the person taking the action. A physician operating at the level of Universal Ethical Principles practices medicine according to his or her conscience about what is best for the patient, the health of the public, and the needs of the profession. An example of this is the pediatrician working who is working with an undocumented immigrant with a congenital heart defect and devotes uncompensated hours to identify a hospital willing to provide pro-bono surgical treatment to the child. The pressures and standards of physicians’ professional roles tend to push us toward greater moral development. The burden of being held to a higher standard is also a privilege. Because we are forced to think about public health and allocation of scarce resources, for example, we are encouraged to think beyond the Conventional level of morality. However, even as we aspire to make our decisions from a principled level of morality, many of us are vulnerable to moving back and forth among the stages, particularly if our personal and professional moralities are not in alignment. As we observe what happens on the political stage, let us be reminded to be morally exacting of ourselves to maintain the highest ethical ideals and behavior. ■Claire Zilber, M.D., is chair of the Ethics Committee of the Colorado Psychiatric Society, a consultant to APA’s Ethics Committee, and a private practitioner in Denver. ISSUES NewArchived

APA Commentary on Ethics in Practice: An Additional Ethics Resource

APA Commentary on Ethics in Practice: An Additional Ethics Resource

Krizna stanja i primjena mjera prisile u psihijatriji

The article deals with phenomena of aggression and violence in humans with special attention to mental illnesses. Crisis and violent behaviour do not occur only in psychiatry. It can happen in any context or circumstance, and any person could either fall victim or be the perpetrator. Knowledge of multicausality and complexity as well as of individual environmental and situational factors that can lead to violent behaviour has little power of prediction. Statistical indicators can conceal false positive and false negative results, whereby the error of assessment can dramatically increase the risk of some behaviour or lead to an unjustified suspension of human rights of freedom. The use of coercion in psychiatry is necessary only in exceptional situations where dangerous behaviour directly threatens the life and health of the person or the environment or property. Positive legislation, in particular the Law on the Protection of Persons with Mental Disabilities (Narodne novine 76/2014) and the Ordinance on the Types and Methods of Enforcement of Coercion to a Person with Serious Mental Disorders (Narodne novine 16/2015) further protects the rights of the mentally ill and prescribes the type and mode of coercion as well as procedures for handling. Professional psychiatric societies have provided additional guidelines and treatment strategies. The paper emphasizes the need for better conditions, infrastructure and human resources, with continuous improvement and evaluation of the quality of work in psychiatry. In conclusion, the standards and ethical issues of society and a broad spectrum of activities are being discussed, from destigmatization, through better access to services to standards of living and social inclusion, which can indirectly lead to a significant reduction of violence in society.

Indian Psychiatric Society Survey on Clinical Practice Guidelines.

Aim:This survey aimed to assess the utility of the earlier published clinical practice guidelines (CPGs) by IPS and to understand the expectations of members of Indian Psychiatric Society from the proposed revised CPGs. In addition, the survey also evaluated the current level of practice of psychiatry in terms of availability of different investigation facilities, prescription patterns in terms of use of polypharmacy, and competence in carrying out certain nonpharmacological treatments.Methodology:An online survey was received by 3475 psychiatrist, of whom 608 (17.5%) participants completed the survey.Results:Almost all (93.8%) of the psychiatrists agreed that there should be separate CPGs for Indian setting. In terms of problems with the previous version of the CPGs, this survey shows that the previous version of guidelines was used in making clinical decisions by only one-third (31.25%) of the participating psychiatrists. The major limitations of the previous version of CPGs which were pointed out included the lack of consideration of socio-cultural issues (33.2%), lack of recommendations for many clinical situations that are encountered in clinical practice (43.15) and poor dissemination (35.2%). In terms of expectations, the membership expects the society to come up with guidelines, which are shorter in length (82.2%), has significant proportion of information in the form of tables and flow diagrams (58.7%), besides the evidence base must also take expert opinions into account (84.7%), must be circulated before adopting (88.7%), must be disseminated by displaying the same on the website (72%), and also by sending the same by E-mails (62%). Further, the membership expects the IPS to design online continuing medical education program on CPGs (54.3%). The survey also suggests that it is feasible on the part of more than two-third of the psychiatrists to monitor the metabolic parameters in routine clinical practice and carryout various nonpharmacological treatments. Majority of the psychiatrist opined that polypharmacy is not used in more than 25% of patients with schizophrenia and depression and hence the use of polypharmacy should be recommended judiciously.Conclusion:This survey shows that the membership of the IPS is interested in having own guidelines for the management of various psychiatric disorders in Indian setting. Further, the survey provides insights into why the previous versions of the guidelines were not very popular and what IPS should do improve the acceptability of guidelines in future.

Clinical Practice Guidelines for Management of Sexual Dysfunction

Sexual functioning is a complex bio-psycho-social process, coordinated by the neurological, vascular and endocrine systems. In addition to the biological factors, the psychosocial factors like societal and religious beliefs, health status, personal experience, ethnicity and socio-demographic conditions, and psychological status of the person/couple play an important role in adequate sexual functioning of a person. In addition, sexual activity incorporates interpersonal relationships, each partner bringing unique attitudes, needs and responses into the coupling. A breakdown in any of these areas may lead to sexual dysfunction. Prevalence of sexual dysfunction in general population is very high. It is suggested that about 43% of women and 31% of men have one or other kind of sexual dysfunction. Among men, premature ejaculation is the most common male sexual dysfunction. There is lack of consensus with regards to the most common sexual dysfunction in women with some studies reporting hypoactive sexual desire disorder to be the most common entity, followed by orgasmic and arousal disorders; whereas other studies suggest that difficulty achieving orgasm and vaginal dryness to be the most common type of sexual dysfunction in women. Problems of sexual dysfunction may be lifelong or acquired, general or situational. Although sexual problems are highly prevalent, these are frequently under-recognized and under-diagnosed in clinical practice. It is also noted that clinicians also have lack of understanding about the approach for identification and evaluation of sexual problem. It is often recommended that the treating psychiatrists and collaborating specialists need to possess broad knowledge and appropriate attitude towards human sexuality. The essential concepts underlying the management of sexual problems are adoption of a patient-centered framework for evaluation and treatment. Principles of evidence-based medicine may be followed in both men and women in diagnostic and treatment planning and adoption of common management approaches for sexual dysfunction. The purpose of these guidelines is to present a framework for the evaluation, treatment, and follow-up of the patient/couple, who presents with sexual dysfunction. We hope that these guidelines would help in facilitating proper management of patients presenting with various types of sexual dysfunction. These guidelines are to be read along with the earlier version of Indian Psychiatric Society Guidelines.

Clinical Practice Guidelines for Management of Schizophrenia.

Clinical Practice Guidelines for Management of Schizophrenia.

"IDEAS" and the IPS.

Byline: K. Kumar Sir, The efforts to include disabled psychiatrically ill individuals in the ambit of the welfare programs for the disabled in India have a delayed start and a long checkered course. Psychiatrists and other mental health workers had been making ardent appeals and personal efforts in discrete and discontinuous ways, to seek parity of disabled mentally ill persons with mentally retarded and physically disabled persons. Since the 1960s and 1970s, the union and state governments, parliament and state assemblies, and socially committed conscientious citizens started talking on and taking up the cause of disabled persons' care, support, and sustenance, on the line of welfare programs prevailing and prospering in developed nations. During the 1980s and 1990s, the concern and care for the disabled individuals gained attention from the health sector and social welfare sector. The Social Welfare Ministry (as it was called then) of Government of India started to convene meetings on drafting a suitable comprehensive act, incorporating welfare programs for physically disabled persons. Mental retardation also was brought into the gamut of disabilities, thanks to the effort of pioneers in the field of care of persons with mental retardation. Some of us who had been active at the Indian Psychiatric Society at those times addressed the Social Welfare Ministry and got invited to attend the meetings meant for evolving disability welfare programs. Along with many seniors like Dr. A. Venkoba Rao, Dr. S. M. Channabasavanna, Dr. M. Sarada Menon, Dr. L. P. Shah, some juniors like me also had the privilege of attending such meetings. I distinctly remember Sri. Pandey, the then joint secretary, Social Welfare Department, a very perceptive officer who was the coordinator/convener for most of these meetings that were attended by professionals, community leaders, and legal experts. Although we could convey, and to some extent, convince them about the genuine need and justification of including chronic mentally ill persons in the catchment for welfare programs, lack of a scale to evaluate and quantify behavioral and social disability of these patients emerged as a major, or even an absolute hurdle in accepting them, on par with other disabled individuals, defined well. Although the Persons with Disabilities Act (PDA) 1995 included chronic mentally ill as the last category of disabilities, lack of a scale for evaluation and grading psychiatric disability made it impossible for the government to extend disability assistance benefits under PDA for our disabled patients on par with other disabled persons. The utmost and urgent felt need for such an evaluation and scoring scale for psychiatrically disabled persons loomed large, in front of Indian psychiatrists and the IPS for few years since then. In 2001, at the Annual National Conference Indian Psychiatric Society (ANCIPS) Pune, a Task Force, with Dr. Thara (Scarf, Chennai) as chairperson and Dr. T. Murali (National Institute of Mental Health and Neurosciences [NIMHANS]) as convener, was constituted for preparing such a scale, and the task was taken up on an urgent pace to be completed in an year. Galvanized as the premium project of the IPS for the year, it was earnestly taken up by the task force. Dr. S. Nambi, the then secretary general of IPS extended his valuable help in coordinating the work. Despite some operational difficulties and financial limitations, the Task Force did a commendable work in evolving the draft of the Indian Disability Evaluation and Assessment Scale (IDEAS) and field-tested it in ten centers across the country. In the inauguration of ANCIPS 2002 at Kolkata, I had the pleasant privilege of releasing the IDEAS, fulfilling the mission initiated as IPS President in ANCIPS, Pune, in 2001. …

Preamble of the Clinical Practice Guidelines.

From 2005 onwards, the Indian Psychiatric Society came up with treatment guidelines for various psychiatric disorders to meet the requirements of our patients in the context of prevailing existing resources. There have been several developments in the management of these disorders since then. In view of the same, it was decided to update the existing treatment guidelines for various psychiatric disorders. These new set of guidelines attempt to update the previous guidelines by emphasizing what is new in the field. These guidelines should be read in conjunction with the earlier version of the clinical practice guidelines as developed and published by the Indian Psychiatric Society in the year 2005 & 2006. These guidelines are not particularly applicable to any specific treatment setting and may need minor modifications to suit the needs of patients in a specific setting. The recommendations are primarily meant for adult patients. The needs of children or the elderly may be different. Finally, it is expected that recommendations made will have to be tailored to suit the needs of individual patients. Although these guidelines focus on management of various disorders, yet the clinicians need to remember that management must focus on the whole patient and not just the disorder. The recommendations given as part of the revised guidelines are based on the available evidence base, expert consensus and the feedback obtained from the membership. Several factors influence the treatment of various psychiatric disorders. Common ingredients of management plan are shown in Table-1. Particular consideration needs to be given to clinical parameters like cross-sectional and longitudinal course of symptoms, type of predominant symptoms, presence or absence of medical comorbidity, comorbid substance abuse/dependence, life stage of patients and their special needs. Socio-cultural factors e.g. beliefs about the illness and their treatments are particularly important, as are the availability of treatment-resources. The general goals of treatment should be to decrease the frequency, severity and impact of episodes (exacerbations) and maximize functioning between the episodes. Specific goals will depend on the specific phases of illness.Table 1: Common ingredients of a management plan

Clinical Practice Guidelines for Management of Bipolar Disorder.

Bipolar disorder (BPAD) is a serious mental disorder characterized by episodes of depression, hypomania/mania and mixed episodes, with interepisodic recovery. However, many patients with BPAD continue to exhibit residual symptoms in the interepisodic period. The illness usually starts in adolescence or early adulthood and has significant negative impact on the life of the sufferer and their caregivers. Patients with BPAD encounter educational difficulties, job related problems, interpersonal difficulties, psychosocial dysfunction, disability, marital problems, multiple suicidal attempts, completed suicide and medication side effects. Additionally patients with BPAD have high rates of physical and psychiatric comorbidity. The prevalence rates of BPAD vary from country to country. A large multinational study suggests that lifetime prevalence of BPAD-I ranges from 0-1% with a mean of 0.6 (SD-0.4). The prevalence rate of BPAD-II ranges from 0 to 1.1% with a mean of 0.4 (SD-0.3). Additionally a significant proportion of patients have been shown to have subthreshold BPAD with a range of 0.1 to 2.4% with a mean of 1.4 (SD-0.8). There is no nationwide study to evaluate the prevalence rates of BPAD in India. In a country like India, patients have limited resources, poor knowledge about the disorder and treatment; have inadequate access to the health care facilities, which makes treatment of BPAD a challenge. Indian Psychiatric Society (IPS) made first attempt to formulate Clinical Practice Guidelines (CPGs) for management of BPAD in 2005. Since then, over the last one decade there have been several developments, especially in the form of emergence of new evidence for some of the pharmacological agents. Accordingly, these new guidelines attempt to update the previous guidelines published by IPS. These guidelines should be read along with the earlier version of the CPGs, published by IPS in 2005.

Psychopharmacology curriculum for psychiatric residents

Summary Background: Postgraduate teaching of psychiatric residents in the important field of psychopharmacology and pharmacotherapy is insufficient regarding number of hours of theoretical teaching and practical training, content and structure and varies widely. Education based on controlled trials (evidence-based) may interfere with daily life real world experience and questions of doctors. Method: Data available from national psychiatric societies and from the literature are presented as well as a recently proposed German curriculum and learning catalogue. The latter includes general pharmacology including pharmacokinetics, neurobiological principles, clinical pharmacology of different classes of psychotropics (antidepressants, antipsychotics, mood stabilizers, anxiolytics, hypnotics, stimulants etc.), special aspects (e.g. pregnancy, geriatric patients) as well as ethical, legal and economic aspects. About 160 hours of theoretical education are proposed, clinical teaching should be interactive, with vignettes and supervision covering about 300 hours. There is a need for standardization of psychopharmacology-pharmacopsychiatry teaching at the European level.

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