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Greater focus on therapeutic relationship could improve VAMC outcomes
ATLANTA – It may be time for the U.S. Department of Veterans Affairs’ Veterans Health Administration to consider new ways of integrating its approaches to mental health care to better serve its patients, Dr. Harold Kudler said at the annual meeting of the American Psychiatric Association.
The VA’s original mental health program began as one designed to bridge a gap in services for the thousands of American veterans in need of psychiatric care at the end of World War I. The program, as promoted by Dr. Thomas Salmon, involved the concept of mental hygiene, which encompasses a dynamic balance between personal, environmental, and biological factors, and includes the possibility of recovery.
However, the release of the DSM-III in 1980 – which established the diagnosis of posttraumatic stress disorder – marked a shift toward the “medicalization” of mental health. This medicalized approach largely left the person, the family, and the community out of the mental health care equation, according to Dr. Kudler, adjunct associate professor in the department of psychiatry and behavioral sciences at Duke University, Durham, N.C.
Readjustment Counseling Services (RCS), also called vet centers, emerged as an answer to this problem.
“Concurrent almost exactly in time with the release of DSM-III and its medicalization and inclusion of PTSD was a rising awareness of post-deployment mental health issues among Vietnam veterans in very human terms,” explained Dr. Kudler, also chief consultant for mental health services at the Veterans Health Administration. “As VA medical centers [VAMCs] embraced the zeitgeist of medicalizing mental health, the vet center system was designed to engage veterans on their own terms rather than in medical terms, in very deliberate ways.”
Readjustment Counseling Services provided a critically important alternative to the VAMCs, as they approached deployment mental health in personal, family, community, and cultural terms, he said.
Vet centers are “specifically not medical,” Dr. Kudler said, noting that they are physically separate from VAMCs, have separate administrative and fiscal structures, have separate training and systems of records, and involve different paths for different veterans.
He described these differences as “good fences,” each of which helped to establish the vet centers as “a critically important pathway for veterans of Vietnam and other military operations before and since.” Still, the emphasis on distinguishing vet centers from VAMCs may reflect “the underlying tension of a conceptual bifurcation in the VA’s approach to deployment mental health, which is rooted in the debates of late 20th-century mental health and continuing today,” Dr. Kudler said.
Emphasis on evidence
The “essential missing link” in the VAMC approach is the therapeutic relationship. That is, the VA’s Clinical Practice Guidelines reflect “landmark success” in identifying and disseminating evidence-based best treatments. In fact, the VA is recognized by the Institute of Medicine as a world leader in training its own mental health staff in evidence-based treatment for PTSD, he noted.
But most evidence-based treatments disseminated by the VA are manualized therapies, such as Prolonged Exposure and Cognitive Processing therapy. Training typically focuses on mastering specific skills and maintaining adherence to the manuals rather than on the strength and nature of the therapeutic relationship, and on the disciplined assessment and management of the therapeutic relationship as a key component of psychotherapy, he said.
The APA Interdivisional Task Force on Evidence-Based Therapy (Divisions 12 & 29) addressed the matter of the therapeutic relationship and concluded that the relationship makes substantial and consistent contributions to psychotherapy outcome independent of the specific type of treatment, and that it contributes at least as much to the success or failure of treatment as does the particular treatment method.
The task force stated that practice and treatment guidelines should address explicitly therapist behaviors and qualities that promote a facilitative therapy relationship, and that efforts to promulgate best practices or evidence-based practices without including the relationship “are seriously incomplete and potentially misleading.”
“And I would just add, unscientific,” he said.
“The VA could significantly advance the field of mental health by modeling integration of EBTs [evidence-based treatments] and bringing attention to the therapeutic relationship, and it needs to be built into our clinical practice guidelines,” he said, noting that this suggestion is based on more than a century of research and clinical experience, and that addressing the therapeutic relationship in the guidelines will be modeled worldwide and will result in insurance companies “paying for people to pay attention to the therapeutic relationship.”
VAMC and vet center staff could enhance the effort through a convergence of their conceptualizations, engagement strategies, and approaches to care, he added.
He stressed that he is not suggesting a merger of the two, but rather that the VAMCs learn from what has made the vet centers so successful, so that clinical outcomes at the VAMCs can be optimized.
Start with the RCS’s highly individualized, culturally competent approach to veterans, he suggested, adding that practical steps toward this approach might include:
• Joint training of VAMC and RCS clinical and administrative staff, which could raise awareness of history, functions, and opportunities for collaboration.
• Creation of new venues for formal and informal discussion between RCS and VAMC teams about shared cases while preserving separate record systems.
• Development of formal sharing agreements between VAMCs and vet centers to ensure that veterans have needed access to the unique benefits of each program, with coordination between programs.
“These recommendations restore balance and shared strategic direction of the VAMC and vet center programs,” he said, noting that they also would “bring us full circle to Salmon’s vision of mental hygiene in which veterans, families, communities, health professionals, health systems, policy makers, and government at all levels partner to recognize and address mental health problems, deployment-related and otherwise, and – whenever possible – prevent them. Such an integration would truly promote veteran-centered care,” he concluded.
Dr. Kudler reported having no disclosures.
ATLANTA – It may be time for the U.S. Department of Veterans Affairs’ Veterans Health Administration to consider new ways of integrating its approaches to mental health care to better serve its patients, Dr. Harold Kudler said at the annual meeting of the American Psychiatric Association.
The VA’s original mental health program began as one designed to bridge a gap in services for the thousands of American veterans in need of psychiatric care at the end of World War I. The program, as promoted by Dr. Thomas Salmon, involved the concept of mental hygiene, which encompasses a dynamic balance between personal, environmental, and biological factors, and includes the possibility of recovery.
However, the release of the DSM-III in 1980 – which established the diagnosis of posttraumatic stress disorder – marked a shift toward the “medicalization” of mental health. This medicalized approach largely left the person, the family, and the community out of the mental health care equation, according to Dr. Kudler, adjunct associate professor in the department of psychiatry and behavioral sciences at Duke University, Durham, N.C.
Readjustment Counseling Services (RCS), also called vet centers, emerged as an answer to this problem.
“Concurrent almost exactly in time with the release of DSM-III and its medicalization and inclusion of PTSD was a rising awareness of post-deployment mental health issues among Vietnam veterans in very human terms,” explained Dr. Kudler, also chief consultant for mental health services at the Veterans Health Administration. “As VA medical centers [VAMCs] embraced the zeitgeist of medicalizing mental health, the vet center system was designed to engage veterans on their own terms rather than in medical terms, in very deliberate ways.”
Readjustment Counseling Services provided a critically important alternative to the VAMCs, as they approached deployment mental health in personal, family, community, and cultural terms, he said.
Vet centers are “specifically not medical,” Dr. Kudler said, noting that they are physically separate from VAMCs, have separate administrative and fiscal structures, have separate training and systems of records, and involve different paths for different veterans.
He described these differences as “good fences,” each of which helped to establish the vet centers as “a critically important pathway for veterans of Vietnam and other military operations before and since.” Still, the emphasis on distinguishing vet centers from VAMCs may reflect “the underlying tension of a conceptual bifurcation in the VA’s approach to deployment mental health, which is rooted in the debates of late 20th-century mental health and continuing today,” Dr. Kudler said.
Emphasis on evidence
The “essential missing link” in the VAMC approach is the therapeutic relationship. That is, the VA’s Clinical Practice Guidelines reflect “landmark success” in identifying and disseminating evidence-based best treatments. In fact, the VA is recognized by the Institute of Medicine as a world leader in training its own mental health staff in evidence-based treatment for PTSD, he noted.
But most evidence-based treatments disseminated by the VA are manualized therapies, such as Prolonged Exposure and Cognitive Processing therapy. Training typically focuses on mastering specific skills and maintaining adherence to the manuals rather than on the strength and nature of the therapeutic relationship, and on the disciplined assessment and management of the therapeutic relationship as a key component of psychotherapy, he said.
The APA Interdivisional Task Force on Evidence-Based Therapy (Divisions 12 & 29) addressed the matter of the therapeutic relationship and concluded that the relationship makes substantial and consistent contributions to psychotherapy outcome independent of the specific type of treatment, and that it contributes at least as much to the success or failure of treatment as does the particular treatment method.
The task force stated that practice and treatment guidelines should address explicitly therapist behaviors and qualities that promote a facilitative therapy relationship, and that efforts to promulgate best practices or evidence-based practices without including the relationship “are seriously incomplete and potentially misleading.”
“And I would just add, unscientific,” he said.
“The VA could significantly advance the field of mental health by modeling integration of EBTs [evidence-based treatments] and bringing attention to the therapeutic relationship, and it needs to be built into our clinical practice guidelines,” he said, noting that this suggestion is based on more than a century of research and clinical experience, and that addressing the therapeutic relationship in the guidelines will be modeled worldwide and will result in insurance companies “paying for people to pay attention to the therapeutic relationship.”
VAMC and vet center staff could enhance the effort through a convergence of their conceptualizations, engagement strategies, and approaches to care, he added.
He stressed that he is not suggesting a merger of the two, but rather that the VAMCs learn from what has made the vet centers so successful, so that clinical outcomes at the VAMCs can be optimized.
Start with the RCS’s highly individualized, culturally competent approach to veterans, he suggested, adding that practical steps toward this approach might include:
• Joint training of VAMC and RCS clinical and administrative staff, which could raise awareness of history, functions, and opportunities for collaboration.
• Creation of new venues for formal and informal discussion between RCS and VAMC teams about shared cases while preserving separate record systems.
• Development of formal sharing agreements between VAMCs and vet centers to ensure that veterans have needed access to the unique benefits of each program, with coordination between programs.
“These recommendations restore balance and shared strategic direction of the VAMC and vet center programs,” he said, noting that they also would “bring us full circle to Salmon’s vision of mental hygiene in which veterans, families, communities, health professionals, health systems, policy makers, and government at all levels partner to recognize and address mental health problems, deployment-related and otherwise, and – whenever possible – prevent them. Such an integration would truly promote veteran-centered care,” he concluded.
Dr. Kudler reported having no disclosures.
ATLANTA – It may be time for the U.S. Department of Veterans Affairs’ Veterans Health Administration to consider new ways of integrating its approaches to mental health care to better serve its patients, Dr. Harold Kudler said at the annual meeting of the American Psychiatric Association.
The VA’s original mental health program began as one designed to bridge a gap in services for the thousands of American veterans in need of psychiatric care at the end of World War I. The program, as promoted by Dr. Thomas Salmon, involved the concept of mental hygiene, which encompasses a dynamic balance between personal, environmental, and biological factors, and includes the possibility of recovery.
However, the release of the DSM-III in 1980 – which established the diagnosis of posttraumatic stress disorder – marked a shift toward the “medicalization” of mental health. This medicalized approach largely left the person, the family, and the community out of the mental health care equation, according to Dr. Kudler, adjunct associate professor in the department of psychiatry and behavioral sciences at Duke University, Durham, N.C.
Readjustment Counseling Services (RCS), also called vet centers, emerged as an answer to this problem.
“Concurrent almost exactly in time with the release of DSM-III and its medicalization and inclusion of PTSD was a rising awareness of post-deployment mental health issues among Vietnam veterans in very human terms,” explained Dr. Kudler, also chief consultant for mental health services at the Veterans Health Administration. “As VA medical centers [VAMCs] embraced the zeitgeist of medicalizing mental health, the vet center system was designed to engage veterans on their own terms rather than in medical terms, in very deliberate ways.”
Readjustment Counseling Services provided a critically important alternative to the VAMCs, as they approached deployment mental health in personal, family, community, and cultural terms, he said.
Vet centers are “specifically not medical,” Dr. Kudler said, noting that they are physically separate from VAMCs, have separate administrative and fiscal structures, have separate training and systems of records, and involve different paths for different veterans.
He described these differences as “good fences,” each of which helped to establish the vet centers as “a critically important pathway for veterans of Vietnam and other military operations before and since.” Still, the emphasis on distinguishing vet centers from VAMCs may reflect “the underlying tension of a conceptual bifurcation in the VA’s approach to deployment mental health, which is rooted in the debates of late 20th-century mental health and continuing today,” Dr. Kudler said.
Emphasis on evidence
The “essential missing link” in the VAMC approach is the therapeutic relationship. That is, the VA’s Clinical Practice Guidelines reflect “landmark success” in identifying and disseminating evidence-based best treatments. In fact, the VA is recognized by the Institute of Medicine as a world leader in training its own mental health staff in evidence-based treatment for PTSD, he noted.
But most evidence-based treatments disseminated by the VA are manualized therapies, such as Prolonged Exposure and Cognitive Processing therapy. Training typically focuses on mastering specific skills and maintaining adherence to the manuals rather than on the strength and nature of the therapeutic relationship, and on the disciplined assessment and management of the therapeutic relationship as a key component of psychotherapy, he said.
The APA Interdivisional Task Force on Evidence-Based Therapy (Divisions 12 & 29) addressed the matter of the therapeutic relationship and concluded that the relationship makes substantial and consistent contributions to psychotherapy outcome independent of the specific type of treatment, and that it contributes at least as much to the success or failure of treatment as does the particular treatment method.
The task force stated that practice and treatment guidelines should address explicitly therapist behaviors and qualities that promote a facilitative therapy relationship, and that efforts to promulgate best practices or evidence-based practices without including the relationship “are seriously incomplete and potentially misleading.”
“And I would just add, unscientific,” he said.
“The VA could significantly advance the field of mental health by modeling integration of EBTs [evidence-based treatments] and bringing attention to the therapeutic relationship, and it needs to be built into our clinical practice guidelines,” he said, noting that this suggestion is based on more than a century of research and clinical experience, and that addressing the therapeutic relationship in the guidelines will be modeled worldwide and will result in insurance companies “paying for people to pay attention to the therapeutic relationship.”
VAMC and vet center staff could enhance the effort through a convergence of their conceptualizations, engagement strategies, and approaches to care, he added.
He stressed that he is not suggesting a merger of the two, but rather that the VAMCs learn from what has made the vet centers so successful, so that clinical outcomes at the VAMCs can be optimized.
Start with the RCS’s highly individualized, culturally competent approach to veterans, he suggested, adding that practical steps toward this approach might include:
• Joint training of VAMC and RCS clinical and administrative staff, which could raise awareness of history, functions, and opportunities for collaboration.
• Creation of new venues for formal and informal discussion between RCS and VAMC teams about shared cases while preserving separate record systems.
• Development of formal sharing agreements between VAMCs and vet centers to ensure that veterans have needed access to the unique benefits of each program, with coordination between programs.
“These recommendations restore balance and shared strategic direction of the VAMC and vet center programs,” he said, noting that they also would “bring us full circle to Salmon’s vision of mental hygiene in which veterans, families, communities, health professionals, health systems, policy makers, and government at all levels partner to recognize and address mental health problems, deployment-related and otherwise, and – whenever possible – prevent them. Such an integration would truly promote veteran-centered care,” he concluded.
Dr. Kudler reported having no disclosures.
EXPERT ANALYSIS AT THE APA ANNUAL MEETING
Mental health workers urged to guard against the possibility of patient violence
ATLANTA – About half of all mental health professionals at all levels and in all practice settings can expect to be threatened by a patient at some point in their career, with as many as 40% sustaining a patient-inflicted injury, according to a researcher.
Despite these numbers, there exist few formal protocols for mental health personnel to learn how to protect themselves against the risk of being harmed by a patient.
Why this is, and what can be done to fill this void, has become an area of deep interest for Dr. Michael Knable, the executive director of the Sylvan C. Herman Foundation in Frederick, Md., a major underwriter for Clearview Communities’ residential treatment facilities for persons with mental illness, where Dr. Knable is also the medical director.“I really only got interested in this because of these two friends of mine who were killed [by patients],” Dr. Knable said in an interview at the annual meeting of the American Psychiatric Association.
His two friends were Dr. Wayne Fenton and Dr. Mark Lawrence, two Washington-based psychiatrists killed in their private offices by patients in 2006 and 2011, respectively.
“It’s true that the seriously mentally ill are more likely to be victimized than to be the victimizers, but it’s also true that, especially in acute settings like emergency rooms and hospitals, that they can be very violent,” Dr. Knable said in the interview.
Based on his research, Dr. Knable said the risks to practitioners include being physically threatened, stalked, sued, stabbed, and even shot to death, among other injuries. According to statistics from the Department of Justice, between 2004 and 2009, mental health workers were second only to law enforcement officers in sustaining on-the-job violence: 38 victims per 1,000 mental health workers, compared with 48 per 1,000 law enforcement officers.
Dr. Knable conducted a literature review of all published surveys of mental health professionals ranging from those with 4-year degrees, to social workers, to psychiatrists. He found that the typical profile of a mental health provider murdered by a patient is a female case worker in her 30s who has been shot to death. The typical patient perpetrator is a male, also in his 30s, who has a form of schizophrenia, a history of violence, and non-adherence to medication. More than half of these individuals also have a history of involuntary hospitalization.
“Our field attracts a lot of idealistic people who want to help others,” said Dr. Knable. “But until they’ve experienced [violence], they simply don’t evaluate the risks carefully enough.”
The National Institute of Mental Health’s Clinical Antipsychotic Treatment Intervention Effectiveness (CATIE) trial found that 19.1% of 1,410 patients with schizophrenia had a violent episode in the prior six months.
A meta-analysis of 110 studies of more than 45,000 patients with schizophrenia also found that nearly 20% had a history of violence, and review of registry data from Sweden showed that in 82,647 patients with schizophrenia, 6.5% of men and 1.4% of women had been convicted of a violent crime when not taking their medication. When they were taking their prescribed medications, crime rates fell by 45% in the cohort taking antipsychotics and 24% in those taking mood stabilizers.
Given these data, when asked why there are not more mandatory personal security training programs for mental health personnel, Dr. Knable said it comes down to a mix of naiveté and politics.
“The perception is that if you worry about this, you are stigmatizing the patient, and, to a certain extent, you are. But my desire is to be factual and to know what we’re really dealing with,” Dr. Knable said. Those in his profession most likely to underestimate the seriousness are those in private practice who “aren’t on the front lines” treating persons with serious mental illnesses like schizophrenia.
The national debate over gun control in the context of persons with mental illness also clouds the issue, he said. “People are afraid it will be stigmatizing and keep people out of treatment to say it, but if you have had an involuntary hospitalization, you should not be allowed to have a gun.”
In addition to taking a danger assessment of a patient in the pre-screening interview, Dr. Knable recommended clinicians set up their office so that there is a desk between them and the patient, and more importantly, that the patient is not between the clinician and the exit. Have an established escape route and consider installing cameras in the waiting area so you can see patients before they enter your office. Be aware of solo meetings such as after hours or on weekends. Above all, he said it was best to see potentially violent patients only in tandem with a member of that person’s family, a colleague, or even a security officer.“Before my friends were killed, I was just like everybody else. I just went to work and thought, ‘Well, you just have to be careful.’ I thought I had good instincts. But now, I think there is a lot of room for study and training on this issue.”
On Twitter @whitneymcknight
This article was updated May 17, 2016.
ATLANTA – About half of all mental health professionals at all levels and in all practice settings can expect to be threatened by a patient at some point in their career, with as many as 40% sustaining a patient-inflicted injury, according to a researcher.
Despite these numbers, there exist few formal protocols for mental health personnel to learn how to protect themselves against the risk of being harmed by a patient.
Why this is, and what can be done to fill this void, has become an area of deep interest for Dr. Michael Knable, the executive director of the Sylvan C. Herman Foundation in Frederick, Md., a major underwriter for Clearview Communities’ residential treatment facilities for persons with mental illness, where Dr. Knable is also the medical director.“I really only got interested in this because of these two friends of mine who were killed [by patients],” Dr. Knable said in an interview at the annual meeting of the American Psychiatric Association.
His two friends were Dr. Wayne Fenton and Dr. Mark Lawrence, two Washington-based psychiatrists killed in their private offices by patients in 2006 and 2011, respectively.
“It’s true that the seriously mentally ill are more likely to be victimized than to be the victimizers, but it’s also true that, especially in acute settings like emergency rooms and hospitals, that they can be very violent,” Dr. Knable said in the interview.
Based on his research, Dr. Knable said the risks to practitioners include being physically threatened, stalked, sued, stabbed, and even shot to death, among other injuries. According to statistics from the Department of Justice, between 2004 and 2009, mental health workers were second only to law enforcement officers in sustaining on-the-job violence: 38 victims per 1,000 mental health workers, compared with 48 per 1,000 law enforcement officers.
Dr. Knable conducted a literature review of all published surveys of mental health professionals ranging from those with 4-year degrees, to social workers, to psychiatrists. He found that the typical profile of a mental health provider murdered by a patient is a female case worker in her 30s who has been shot to death. The typical patient perpetrator is a male, also in his 30s, who has a form of schizophrenia, a history of violence, and non-adherence to medication. More than half of these individuals also have a history of involuntary hospitalization.
“Our field attracts a lot of idealistic people who want to help others,” said Dr. Knable. “But until they’ve experienced [violence], they simply don’t evaluate the risks carefully enough.”
The National Institute of Mental Health’s Clinical Antipsychotic Treatment Intervention Effectiveness (CATIE) trial found that 19.1% of 1,410 patients with schizophrenia had a violent episode in the prior six months.
A meta-analysis of 110 studies of more than 45,000 patients with schizophrenia also found that nearly 20% had a history of violence, and review of registry data from Sweden showed that in 82,647 patients with schizophrenia, 6.5% of men and 1.4% of women had been convicted of a violent crime when not taking their medication. When they were taking their prescribed medications, crime rates fell by 45% in the cohort taking antipsychotics and 24% in those taking mood stabilizers.
Given these data, when asked why there are not more mandatory personal security training programs for mental health personnel, Dr. Knable said it comes down to a mix of naiveté and politics.
“The perception is that if you worry about this, you are stigmatizing the patient, and, to a certain extent, you are. But my desire is to be factual and to know what we’re really dealing with,” Dr. Knable said. Those in his profession most likely to underestimate the seriousness are those in private practice who “aren’t on the front lines” treating persons with serious mental illnesses like schizophrenia.
The national debate over gun control in the context of persons with mental illness also clouds the issue, he said. “People are afraid it will be stigmatizing and keep people out of treatment to say it, but if you have had an involuntary hospitalization, you should not be allowed to have a gun.”
In addition to taking a danger assessment of a patient in the pre-screening interview, Dr. Knable recommended clinicians set up their office so that there is a desk between them and the patient, and more importantly, that the patient is not between the clinician and the exit. Have an established escape route and consider installing cameras in the waiting area so you can see patients before they enter your office. Be aware of solo meetings such as after hours or on weekends. Above all, he said it was best to see potentially violent patients only in tandem with a member of that person’s family, a colleague, or even a security officer.“Before my friends were killed, I was just like everybody else. I just went to work and thought, ‘Well, you just have to be careful.’ I thought I had good instincts. But now, I think there is a lot of room for study and training on this issue.”
On Twitter @whitneymcknight
This article was updated May 17, 2016.
ATLANTA – About half of all mental health professionals at all levels and in all practice settings can expect to be threatened by a patient at some point in their career, with as many as 40% sustaining a patient-inflicted injury, according to a researcher.
Despite these numbers, there exist few formal protocols for mental health personnel to learn how to protect themselves against the risk of being harmed by a patient.
Why this is, and what can be done to fill this void, has become an area of deep interest for Dr. Michael Knable, the executive director of the Sylvan C. Herman Foundation in Frederick, Md., a major underwriter for Clearview Communities’ residential treatment facilities for persons with mental illness, where Dr. Knable is also the medical director.“I really only got interested in this because of these two friends of mine who were killed [by patients],” Dr. Knable said in an interview at the annual meeting of the American Psychiatric Association.
His two friends were Dr. Wayne Fenton and Dr. Mark Lawrence, two Washington-based psychiatrists killed in their private offices by patients in 2006 and 2011, respectively.
“It’s true that the seriously mentally ill are more likely to be victimized than to be the victimizers, but it’s also true that, especially in acute settings like emergency rooms and hospitals, that they can be very violent,” Dr. Knable said in the interview.
Based on his research, Dr. Knable said the risks to practitioners include being physically threatened, stalked, sued, stabbed, and even shot to death, among other injuries. According to statistics from the Department of Justice, between 2004 and 2009, mental health workers were second only to law enforcement officers in sustaining on-the-job violence: 38 victims per 1,000 mental health workers, compared with 48 per 1,000 law enforcement officers.
Dr. Knable conducted a literature review of all published surveys of mental health professionals ranging from those with 4-year degrees, to social workers, to psychiatrists. He found that the typical profile of a mental health provider murdered by a patient is a female case worker in her 30s who has been shot to death. The typical patient perpetrator is a male, also in his 30s, who has a form of schizophrenia, a history of violence, and non-adherence to medication. More than half of these individuals also have a history of involuntary hospitalization.
“Our field attracts a lot of idealistic people who want to help others,” said Dr. Knable. “But until they’ve experienced [violence], they simply don’t evaluate the risks carefully enough.”
The National Institute of Mental Health’s Clinical Antipsychotic Treatment Intervention Effectiveness (CATIE) trial found that 19.1% of 1,410 patients with schizophrenia had a violent episode in the prior six months.
A meta-analysis of 110 studies of more than 45,000 patients with schizophrenia also found that nearly 20% had a history of violence, and review of registry data from Sweden showed that in 82,647 patients with schizophrenia, 6.5% of men and 1.4% of women had been convicted of a violent crime when not taking their medication. When they were taking their prescribed medications, crime rates fell by 45% in the cohort taking antipsychotics and 24% in those taking mood stabilizers.
Given these data, when asked why there are not more mandatory personal security training programs for mental health personnel, Dr. Knable said it comes down to a mix of naiveté and politics.
“The perception is that if you worry about this, you are stigmatizing the patient, and, to a certain extent, you are. But my desire is to be factual and to know what we’re really dealing with,” Dr. Knable said. Those in his profession most likely to underestimate the seriousness are those in private practice who “aren’t on the front lines” treating persons with serious mental illnesses like schizophrenia.
The national debate over gun control in the context of persons with mental illness also clouds the issue, he said. “People are afraid it will be stigmatizing and keep people out of treatment to say it, but if you have had an involuntary hospitalization, you should not be allowed to have a gun.”
In addition to taking a danger assessment of a patient in the pre-screening interview, Dr. Knable recommended clinicians set up their office so that there is a desk between them and the patient, and more importantly, that the patient is not between the clinician and the exit. Have an established escape route and consider installing cameras in the waiting area so you can see patients before they enter your office. Be aware of solo meetings such as after hours or on weekends. Above all, he said it was best to see potentially violent patients only in tandem with a member of that person’s family, a colleague, or even a security officer.“Before my friends were killed, I was just like everybody else. I just went to work and thought, ‘Well, you just have to be careful.’ I thought I had good instincts. But now, I think there is a lot of room for study and training on this issue.”
On Twitter @whitneymcknight
This article was updated May 17, 2016.
EXPERT ANALYSIS FROM THE APA ANNUAL MEETING
Some improvements seen in neurocognition post-bariatric surgery
ATLANTA – Some patients experienced improvement in at least one neurocognitive domain up to 3 years after having bariatric surgery, a small, systematic review has shown.
The most significant improvements were reported in memory, with nine studies showing some statistically significant improvement in a post-bariatric surgery cohort. Four studies showed statistically significant improvement in attention and executive function, and two did so in language.
Dr. Gurneet S. Thiara, a psychiatry resident at the University of Toronto, presented the findings during a scientific session at this year’s annual meeting of the American Psychiatric Association.
Because the studies that form the basis of the analysis did not follow a standard pre-surgery neurocognitive assessment, the actual scope of bariatric surgery’s impact on neurocognition is hard to determine. This shortcoming provides evidence that instituting a standardized method of psychiatric assessment pre-bariatric surgery could help clinicians better anticipate overall neurocognitive outcomes, he said.
“It’s hard to pinpoint the one domain that affects [this cohort] most,” said Dr. Thiara.
One study included in the analysis showed no neurocognitive improvement, although Dr. Thiara noted this was possibly due to the under- or non-reporting of negative outcomes by researchers who conducted studies that might have met his inclusion criteria.
Dr. Thiara and his colleagues were not able to draw conclusions as to which patients would be affected in which domains and by what mechanism of action. Their analysis did suggest possible relationships between gastric bypass and changes in metabolism, levels of leptin and ghrelin, vascular function, hypoperfusion in the brain, and even shifts in the gut microbiome.
Dr. Thiara sought studies with bariatric surgery patients whose neurocognitive and psychological outcomes were followed anywhere from one to three years post-surgery. After analyzing 422 studies published between January 1990 and August 2015, only ten studies, with patient sample sizes ranging from 10 to 156, met the criteria.
The study was not intended to determine a relationship between neurocognitive outcomes and type of bypass surgery performed, but Dr. Thiara said the majority of the procedures analyzed tended to be Roux-en-Y rather than the gastric bypass sleeve.
On Twitter @whitneymcknight
ATLANTA – Some patients experienced improvement in at least one neurocognitive domain up to 3 years after having bariatric surgery, a small, systematic review has shown.
The most significant improvements were reported in memory, with nine studies showing some statistically significant improvement in a post-bariatric surgery cohort. Four studies showed statistically significant improvement in attention and executive function, and two did so in language.
Dr. Gurneet S. Thiara, a psychiatry resident at the University of Toronto, presented the findings during a scientific session at this year’s annual meeting of the American Psychiatric Association.
Because the studies that form the basis of the analysis did not follow a standard pre-surgery neurocognitive assessment, the actual scope of bariatric surgery’s impact on neurocognition is hard to determine. This shortcoming provides evidence that instituting a standardized method of psychiatric assessment pre-bariatric surgery could help clinicians better anticipate overall neurocognitive outcomes, he said.
“It’s hard to pinpoint the one domain that affects [this cohort] most,” said Dr. Thiara.
One study included in the analysis showed no neurocognitive improvement, although Dr. Thiara noted this was possibly due to the under- or non-reporting of negative outcomes by researchers who conducted studies that might have met his inclusion criteria.
Dr. Thiara and his colleagues were not able to draw conclusions as to which patients would be affected in which domains and by what mechanism of action. Their analysis did suggest possible relationships between gastric bypass and changes in metabolism, levels of leptin and ghrelin, vascular function, hypoperfusion in the brain, and even shifts in the gut microbiome.
Dr. Thiara sought studies with bariatric surgery patients whose neurocognitive and psychological outcomes were followed anywhere from one to three years post-surgery. After analyzing 422 studies published between January 1990 and August 2015, only ten studies, with patient sample sizes ranging from 10 to 156, met the criteria.
The study was not intended to determine a relationship between neurocognitive outcomes and type of bypass surgery performed, but Dr. Thiara said the majority of the procedures analyzed tended to be Roux-en-Y rather than the gastric bypass sleeve.
On Twitter @whitneymcknight
ATLANTA – Some patients experienced improvement in at least one neurocognitive domain up to 3 years after having bariatric surgery, a small, systematic review has shown.
The most significant improvements were reported in memory, with nine studies showing some statistically significant improvement in a post-bariatric surgery cohort. Four studies showed statistically significant improvement in attention and executive function, and two did so in language.
Dr. Gurneet S. Thiara, a psychiatry resident at the University of Toronto, presented the findings during a scientific session at this year’s annual meeting of the American Psychiatric Association.
Because the studies that form the basis of the analysis did not follow a standard pre-surgery neurocognitive assessment, the actual scope of bariatric surgery’s impact on neurocognition is hard to determine. This shortcoming provides evidence that instituting a standardized method of psychiatric assessment pre-bariatric surgery could help clinicians better anticipate overall neurocognitive outcomes, he said.
“It’s hard to pinpoint the one domain that affects [this cohort] most,” said Dr. Thiara.
One study included in the analysis showed no neurocognitive improvement, although Dr. Thiara noted this was possibly due to the under- or non-reporting of negative outcomes by researchers who conducted studies that might have met his inclusion criteria.
Dr. Thiara and his colleagues were not able to draw conclusions as to which patients would be affected in which domains and by what mechanism of action. Their analysis did suggest possible relationships between gastric bypass and changes in metabolism, levels of leptin and ghrelin, vascular function, hypoperfusion in the brain, and even shifts in the gut microbiome.
Dr. Thiara sought studies with bariatric surgery patients whose neurocognitive and psychological outcomes were followed anywhere from one to three years post-surgery. After analyzing 422 studies published between January 1990 and August 2015, only ten studies, with patient sample sizes ranging from 10 to 156, met the criteria.
The study was not intended to determine a relationship between neurocognitive outcomes and type of bypass surgery performed, but Dr. Thiara said the majority of the procedures analyzed tended to be Roux-en-Y rather than the gastric bypass sleeve.
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AT APA 2016
Key clinical point: Neurocognitive testing in patients before bariatric surgery could be a useful tool for tracking overall psychosocial outcomes.
Major finding: Improvements in neurocognitive function were found across several domains in some patients in the years after bariatric surgery.
Data source: Systematic review of neurocognitive outcomes in post-bariatric surgery patients followed for at least 1 year in 10 studies of between 10 and 156 patients.
Disclosures: Dr. Thiara had no relevant disclosures. This study was sponsored in part by the Toronto Western Hospital Bariatric Psychosocial Surgery Program, part of the University Health Network, Toronto, Ont.
