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VHA warns California clinicians on assisted suicide
SAN DIEGO – The Veterans Health Administration has issued strict rules forbidding clinicians from doing anything to help patients kill themselves via physician-assisted suicide, which is now legal in certain cases in California, according to a psychiatrist who updated colleagues at the annual meeting of the American Psychiatric Association.
The VHA says clinicians may not make referrals to physicians who help patients commit suicide, said Kristin Beizai, MD, who is affiliated with the VA San Diego Healthcare System. Nor can they provide information about patient diagnoses outside of medical records or complete forms to support physician aid-in-dying (PAD), she said.
The VA San Diego system received queries from patients about assisted suicide even before the law in mid-2016 allowed physicians to provide deadly medications to some patients, said Dr. Beizai, who’s also with the University of California, San Diego.
“There was a lot of attention coming before the law was active,” she said, and more questions from patients arose after that time.
In addition to California, four other states (Colorado, Oregon, Vermont, and Washington) – and the District of Columbia – allow terminally ill people who meet certain conditions to commit suicide with the assistance of physicians. In addition, a court ruling in Montana appears to allow PAD there.
California’s law allowing PAD took effect after Gov. Jerry Brown in 2015 signed a bill passed by the legislature.
According to a recent report from the state of California, 111 people killed themselves during June-December 2016 by taking deadly medication prescribed by physicians. The patients must self-administer the medications. Of those 111 people, 90% were white, and most had college degrees. The majority had cancer.
The report also said 173 physicians had written 191 total lethal prescriptions, suggesting some patients – perhaps dozens – had not taken the drugs by the end of 2016.
In response to a query from Dr. Beizai about policies regarding PAD, VHA ethics officials sent word that clinicians must butt out when it comes to assisted suicide: “No practitioner functioning within his or her scope of duty may participate in fulfilling requests for euthanasia or PAD,” they said, regardless of what state law allows.
According to the VHA:
- Clinicians may not support PAD through any means, including referrals and evaluations, and federal funds may not be used for PAD.
- Clinicians cannot fill out forms supporting PAD. However, they must not hinder the release of medical records when requested by an outside provider.
- Patients can seek PAD outside of the VHA system if they wish. Patients who ask about PAD must be told that the VHA doesn’t offer the service. “We need to inform them very directly that we do not provide it and are not allowed to participate,” Dr. Beizai said.
- If a patient makes a request regarding PAD, the VHA clinician “must explore the source of the patient’s request and respond with the best possible, medically appropriate care that is consistent with legal standards and is legally permissible.”
Clinicians are encouraged to explore issues like pain, depression, fears, and anxiety, Dr. Beizai said. The VHA has set up a six-step protocol on this front.
But the VHA is making it clear that patients who seek PAD elsewhere must not be abandoned. “Don’t disconnect from the patients if they determine they want to go that route,” said Dr. Beizai, who gave that message to VA San Diego staffers during an educational outreach program regarding PAD.
Dr. Beizai reported no relevant disclosures.
SAN DIEGO – The Veterans Health Administration has issued strict rules forbidding clinicians from doing anything to help patients kill themselves via physician-assisted suicide, which is now legal in certain cases in California, according to a psychiatrist who updated colleagues at the annual meeting of the American Psychiatric Association.
The VHA says clinicians may not make referrals to physicians who help patients commit suicide, said Kristin Beizai, MD, who is affiliated with the VA San Diego Healthcare System. Nor can they provide information about patient diagnoses outside of medical records or complete forms to support physician aid-in-dying (PAD), she said.
The VA San Diego system received queries from patients about assisted suicide even before the law in mid-2016 allowed physicians to provide deadly medications to some patients, said Dr. Beizai, who’s also with the University of California, San Diego.
“There was a lot of attention coming before the law was active,” she said, and more questions from patients arose after that time.
In addition to California, four other states (Colorado, Oregon, Vermont, and Washington) – and the District of Columbia – allow terminally ill people who meet certain conditions to commit suicide with the assistance of physicians. In addition, a court ruling in Montana appears to allow PAD there.
California’s law allowing PAD took effect after Gov. Jerry Brown in 2015 signed a bill passed by the legislature.
According to a recent report from the state of California, 111 people killed themselves during June-December 2016 by taking deadly medication prescribed by physicians. The patients must self-administer the medications. Of those 111 people, 90% were white, and most had college degrees. The majority had cancer.
The report also said 173 physicians had written 191 total lethal prescriptions, suggesting some patients – perhaps dozens – had not taken the drugs by the end of 2016.
In response to a query from Dr. Beizai about policies regarding PAD, VHA ethics officials sent word that clinicians must butt out when it comes to assisted suicide: “No practitioner functioning within his or her scope of duty may participate in fulfilling requests for euthanasia or PAD,” they said, regardless of what state law allows.
According to the VHA:
- Clinicians may not support PAD through any means, including referrals and evaluations, and federal funds may not be used for PAD.
- Clinicians cannot fill out forms supporting PAD. However, they must not hinder the release of medical records when requested by an outside provider.
- Patients can seek PAD outside of the VHA system if they wish. Patients who ask about PAD must be told that the VHA doesn’t offer the service. “We need to inform them very directly that we do not provide it and are not allowed to participate,” Dr. Beizai said.
- If a patient makes a request regarding PAD, the VHA clinician “must explore the source of the patient’s request and respond with the best possible, medically appropriate care that is consistent with legal standards and is legally permissible.”
Clinicians are encouraged to explore issues like pain, depression, fears, and anxiety, Dr. Beizai said. The VHA has set up a six-step protocol on this front.
But the VHA is making it clear that patients who seek PAD elsewhere must not be abandoned. “Don’t disconnect from the patients if they determine they want to go that route,” said Dr. Beizai, who gave that message to VA San Diego staffers during an educational outreach program regarding PAD.
Dr. Beizai reported no relevant disclosures.
SAN DIEGO – The Veterans Health Administration has issued strict rules forbidding clinicians from doing anything to help patients kill themselves via physician-assisted suicide, which is now legal in certain cases in California, according to a psychiatrist who updated colleagues at the annual meeting of the American Psychiatric Association.
The VHA says clinicians may not make referrals to physicians who help patients commit suicide, said Kristin Beizai, MD, who is affiliated with the VA San Diego Healthcare System. Nor can they provide information about patient diagnoses outside of medical records or complete forms to support physician aid-in-dying (PAD), she said.
The VA San Diego system received queries from patients about assisted suicide even before the law in mid-2016 allowed physicians to provide deadly medications to some patients, said Dr. Beizai, who’s also with the University of California, San Diego.
“There was a lot of attention coming before the law was active,” she said, and more questions from patients arose after that time.
In addition to California, four other states (Colorado, Oregon, Vermont, and Washington) – and the District of Columbia – allow terminally ill people who meet certain conditions to commit suicide with the assistance of physicians. In addition, a court ruling in Montana appears to allow PAD there.
California’s law allowing PAD took effect after Gov. Jerry Brown in 2015 signed a bill passed by the legislature.
According to a recent report from the state of California, 111 people killed themselves during June-December 2016 by taking deadly medication prescribed by physicians. The patients must self-administer the medications. Of those 111 people, 90% were white, and most had college degrees. The majority had cancer.
The report also said 173 physicians had written 191 total lethal prescriptions, suggesting some patients – perhaps dozens – had not taken the drugs by the end of 2016.
In response to a query from Dr. Beizai about policies regarding PAD, VHA ethics officials sent word that clinicians must butt out when it comes to assisted suicide: “No practitioner functioning within his or her scope of duty may participate in fulfilling requests for euthanasia or PAD,” they said, regardless of what state law allows.
According to the VHA:
- Clinicians may not support PAD through any means, including referrals and evaluations, and federal funds may not be used for PAD.
- Clinicians cannot fill out forms supporting PAD. However, they must not hinder the release of medical records when requested by an outside provider.
- Patients can seek PAD outside of the VHA system if they wish. Patients who ask about PAD must be told that the VHA doesn’t offer the service. “We need to inform them very directly that we do not provide it and are not allowed to participate,” Dr. Beizai said.
- If a patient makes a request regarding PAD, the VHA clinician “must explore the source of the patient’s request and respond with the best possible, medically appropriate care that is consistent with legal standards and is legally permissible.”
Clinicians are encouraged to explore issues like pain, depression, fears, and anxiety, Dr. Beizai said. The VHA has set up a six-step protocol on this front.
But the VHA is making it clear that patients who seek PAD elsewhere must not be abandoned. “Don’t disconnect from the patients if they determine they want to go that route,” said Dr. Beizai, who gave that message to VA San Diego staffers during an educational outreach program regarding PAD.
Dr. Beizai reported no relevant disclosures.
AT APA
Forced commitments still low under California’s AOT law
Critics have feared that California’s “Laura’s Law,” designed to prevent violence by making it easier for officials to force outpatient care upon people with mental illness who have resisted treatment, would violate the civil rights of Golden State residents.
But early statistics gathered by a Northern California psychiatrist suggest that few people have been forced involuntarily into outpatient care in large counties that have adopted the tougher approach in recent years. Instead, Californians targeted by the law appear to be choosing – under pressure – the alternative of accepting outpatient treatment.
California enacted Laura’s Law in 2003 after the death of a 19-year-old woman named Laura Wilcox at a mental health clinic in Northern California. Ms. Wilcox, who worked at the clinic, and two others were shot to death by a patient whose family had failed to persuade officials to force him to get treatment.
As California’s version of assisted outpatient treatment, or AOT, Laura’s Law, allows courts to order people into outpatient treatment in cases that meet certain criteria. Among other things, the person must have a mental illness, be considered “unlikely to survive safely in the community without supervision,” and have a “history of lack of compliance with treatment.” The law “also obligates any county that implements and accepts the law to provide excellent and comprehensive community-based services, not only for court-ordered patients but anybody who wants care,” Dr. Nelson said in an interview after his presentation.
As a state law, the measure must be adopted on a county-by-county basis. Tiny and remote Nevada County, where the shootings occurred, adopted the policy first when it was forced to do so by a lawsuit, Dr. Nelson said. But other counties were slow to sign on.
“Unlike Kendra’s Law, which passed earlier in New York, and both mandated and funded assisted outpatient treatment for all counties, Laura’s Law was completely unfunded. It was left to the discretion of each county to decide for itself whether or not to implement,” said Dr. Nelson, of Marin County, just north of San Francisco, who has served on the councils of the Northern California Psychiatric Society and California Psychiatric Association.
But things changed in 2013, when the state allowed money from a special tax on wealthy residents to be used for AOT programs, Dr. Nelson said. Counties began implementing Laura’s Law in 2014, and the number has now reached 17, representing about two-thirds of the state’s population, he said.
Dr. Nelson gathered statistics from several of California’s 58 counties. He found that over a period of 5 months of implementation, 59 people were referred to the AOT program, and 12 voluntarily accepted outpatient therapy in San Francisco County, which encompasses the city of San Francisco only and has 864,000 residents.
Over a period of 5 months in San Diego County, which has 3.3 million residents, there were 376 referrals, including those to a program that uses home visits to urge people to accept outpatient care. Twenty people accepted voluntary outpatient treatment. No court-ordered treatment was required for anyone in either San Diego or San Francisco counties.
Over a period of 12 months in Orange County, with 3.2 million residents, there were 389 referrals, and 126 people voluntarily accepted AOT. Only three were ordered into treatment by courts. Over 6 months in Placer County, with just 375,000 residents, eight patients voluntarily accepted AOT, and one was ordered into treatment by a court but refused it.
(The Orange County Register reports that refusal to abide by court-ordered outpatient treatment results in no civil or criminal penalties.)
Los Angeles County, by far the most populous in the state with 10.1 million residents, reported 805 AOT referrals, 30 involuntary commitments to outpatient care, and 239 voluntary agreements to outpatient care. The numbers are from 2016 to 2017, but Dr. Nelson did not have details about the exact period covered.
Dr. Nelson also looked at 7 years of statistics from Nevada County, which was forced into adopting an AOT program by a lawsuit. The county, which has fewer than 100,000 residents, reported 67 referrals to the AOT program and 30 cases of court-ordered treatment.
A report estimates that over the first 30 months of the program, Nevada County saved $1.80 for every $1 spent on its AOT program by preventing acute psychiatric hospitalizations and imprisonment.
The low numbers of forced commitments to outpatient care across the state make sense, Dr. Nelson said, since the law wasn’t intended to “force a bunch of folks with typically high recidivism with mental illness into involuntary treatment.”
Instead, he said, the law has promoted a so-called black robe effect – essentially, a form of intimidation by judge.
Dr. Nelson said he has tracked the debate over forced outpatient care for years and has mixed feelings about the law.
There’s value to coaxing people with mental illness into care when they are unable to recognize their illness, he said. “But there are way too many gaps and holes for people to fall into,” he said. “They have the potential to be mistreated, poorly treated, poorly diagnosed.”
While Laura’s Law requires counties to offer comprehensive outpatient mental health care, “it’s really difficult to know whether the programs are meeting all of the conditions of the law,” Dr. Nelson said.
Still, he said, Laura’s Law is forcing counties to discuss how to care for people with mental illness who are targeted by the legislation, he said. “They are beginning to have a lively conversation about how we are going to reach out to these people and help them, even to just avoid the implementation of Laura’s Law.”
Dr. Nelson has no relevant disclosures.
Critics have feared that California’s “Laura’s Law,” designed to prevent violence by making it easier for officials to force outpatient care upon people with mental illness who have resisted treatment, would violate the civil rights of Golden State residents.
But early statistics gathered by a Northern California psychiatrist suggest that few people have been forced involuntarily into outpatient care in large counties that have adopted the tougher approach in recent years. Instead, Californians targeted by the law appear to be choosing – under pressure – the alternative of accepting outpatient treatment.
California enacted Laura’s Law in 2003 after the death of a 19-year-old woman named Laura Wilcox at a mental health clinic in Northern California. Ms. Wilcox, who worked at the clinic, and two others were shot to death by a patient whose family had failed to persuade officials to force him to get treatment.
As California’s version of assisted outpatient treatment, or AOT, Laura’s Law, allows courts to order people into outpatient treatment in cases that meet certain criteria. Among other things, the person must have a mental illness, be considered “unlikely to survive safely in the community without supervision,” and have a “history of lack of compliance with treatment.” The law “also obligates any county that implements and accepts the law to provide excellent and comprehensive community-based services, not only for court-ordered patients but anybody who wants care,” Dr. Nelson said in an interview after his presentation.
As a state law, the measure must be adopted on a county-by-county basis. Tiny and remote Nevada County, where the shootings occurred, adopted the policy first when it was forced to do so by a lawsuit, Dr. Nelson said. But other counties were slow to sign on.
“Unlike Kendra’s Law, which passed earlier in New York, and both mandated and funded assisted outpatient treatment for all counties, Laura’s Law was completely unfunded. It was left to the discretion of each county to decide for itself whether or not to implement,” said Dr. Nelson, of Marin County, just north of San Francisco, who has served on the councils of the Northern California Psychiatric Society and California Psychiatric Association.
But things changed in 2013, when the state allowed money from a special tax on wealthy residents to be used for AOT programs, Dr. Nelson said. Counties began implementing Laura’s Law in 2014, and the number has now reached 17, representing about two-thirds of the state’s population, he said.
Dr. Nelson gathered statistics from several of California’s 58 counties. He found that over a period of 5 months of implementation, 59 people were referred to the AOT program, and 12 voluntarily accepted outpatient therapy in San Francisco County, which encompasses the city of San Francisco only and has 864,000 residents.
Over a period of 5 months in San Diego County, which has 3.3 million residents, there were 376 referrals, including those to a program that uses home visits to urge people to accept outpatient care. Twenty people accepted voluntary outpatient treatment. No court-ordered treatment was required for anyone in either San Diego or San Francisco counties.
Over a period of 12 months in Orange County, with 3.2 million residents, there were 389 referrals, and 126 people voluntarily accepted AOT. Only three were ordered into treatment by courts. Over 6 months in Placer County, with just 375,000 residents, eight patients voluntarily accepted AOT, and one was ordered into treatment by a court but refused it.
(The Orange County Register reports that refusal to abide by court-ordered outpatient treatment results in no civil or criminal penalties.)
Los Angeles County, by far the most populous in the state with 10.1 million residents, reported 805 AOT referrals, 30 involuntary commitments to outpatient care, and 239 voluntary agreements to outpatient care. The numbers are from 2016 to 2017, but Dr. Nelson did not have details about the exact period covered.
Dr. Nelson also looked at 7 years of statistics from Nevada County, which was forced into adopting an AOT program by a lawsuit. The county, which has fewer than 100,000 residents, reported 67 referrals to the AOT program and 30 cases of court-ordered treatment.
A report estimates that over the first 30 months of the program, Nevada County saved $1.80 for every $1 spent on its AOT program by preventing acute psychiatric hospitalizations and imprisonment.
The low numbers of forced commitments to outpatient care across the state make sense, Dr. Nelson said, since the law wasn’t intended to “force a bunch of folks with typically high recidivism with mental illness into involuntary treatment.”
Instead, he said, the law has promoted a so-called black robe effect – essentially, a form of intimidation by judge.
Dr. Nelson said he has tracked the debate over forced outpatient care for years and has mixed feelings about the law.
There’s value to coaxing people with mental illness into care when they are unable to recognize their illness, he said. “But there are way too many gaps and holes for people to fall into,” he said. “They have the potential to be mistreated, poorly treated, poorly diagnosed.”
While Laura’s Law requires counties to offer comprehensive outpatient mental health care, “it’s really difficult to know whether the programs are meeting all of the conditions of the law,” Dr. Nelson said.
Still, he said, Laura’s Law is forcing counties to discuss how to care for people with mental illness who are targeted by the legislation, he said. “They are beginning to have a lively conversation about how we are going to reach out to these people and help them, even to just avoid the implementation of Laura’s Law.”
Dr. Nelson has no relevant disclosures.
Critics have feared that California’s “Laura’s Law,” designed to prevent violence by making it easier for officials to force outpatient care upon people with mental illness who have resisted treatment, would violate the civil rights of Golden State residents.
But early statistics gathered by a Northern California psychiatrist suggest that few people have been forced involuntarily into outpatient care in large counties that have adopted the tougher approach in recent years. Instead, Californians targeted by the law appear to be choosing – under pressure – the alternative of accepting outpatient treatment.
California enacted Laura’s Law in 2003 after the death of a 19-year-old woman named Laura Wilcox at a mental health clinic in Northern California. Ms. Wilcox, who worked at the clinic, and two others were shot to death by a patient whose family had failed to persuade officials to force him to get treatment.
As California’s version of assisted outpatient treatment, or AOT, Laura’s Law, allows courts to order people into outpatient treatment in cases that meet certain criteria. Among other things, the person must have a mental illness, be considered “unlikely to survive safely in the community without supervision,” and have a “history of lack of compliance with treatment.” The law “also obligates any county that implements and accepts the law to provide excellent and comprehensive community-based services, not only for court-ordered patients but anybody who wants care,” Dr. Nelson said in an interview after his presentation.
As a state law, the measure must be adopted on a county-by-county basis. Tiny and remote Nevada County, where the shootings occurred, adopted the policy first when it was forced to do so by a lawsuit, Dr. Nelson said. But other counties were slow to sign on.
“Unlike Kendra’s Law, which passed earlier in New York, and both mandated and funded assisted outpatient treatment for all counties, Laura’s Law was completely unfunded. It was left to the discretion of each county to decide for itself whether or not to implement,” said Dr. Nelson, of Marin County, just north of San Francisco, who has served on the councils of the Northern California Psychiatric Society and California Psychiatric Association.
But things changed in 2013, when the state allowed money from a special tax on wealthy residents to be used for AOT programs, Dr. Nelson said. Counties began implementing Laura’s Law in 2014, and the number has now reached 17, representing about two-thirds of the state’s population, he said.
Dr. Nelson gathered statistics from several of California’s 58 counties. He found that over a period of 5 months of implementation, 59 people were referred to the AOT program, and 12 voluntarily accepted outpatient therapy in San Francisco County, which encompasses the city of San Francisco only and has 864,000 residents.
Over a period of 5 months in San Diego County, which has 3.3 million residents, there were 376 referrals, including those to a program that uses home visits to urge people to accept outpatient care. Twenty people accepted voluntary outpatient treatment. No court-ordered treatment was required for anyone in either San Diego or San Francisco counties.
Over a period of 12 months in Orange County, with 3.2 million residents, there were 389 referrals, and 126 people voluntarily accepted AOT. Only three were ordered into treatment by courts. Over 6 months in Placer County, with just 375,000 residents, eight patients voluntarily accepted AOT, and one was ordered into treatment by a court but refused it.
(The Orange County Register reports that refusal to abide by court-ordered outpatient treatment results in no civil or criminal penalties.)
Los Angeles County, by far the most populous in the state with 10.1 million residents, reported 805 AOT referrals, 30 involuntary commitments to outpatient care, and 239 voluntary agreements to outpatient care. The numbers are from 2016 to 2017, but Dr. Nelson did not have details about the exact period covered.
Dr. Nelson also looked at 7 years of statistics from Nevada County, which was forced into adopting an AOT program by a lawsuit. The county, which has fewer than 100,000 residents, reported 67 referrals to the AOT program and 30 cases of court-ordered treatment.
A report estimates that over the first 30 months of the program, Nevada County saved $1.80 for every $1 spent on its AOT program by preventing acute psychiatric hospitalizations and imprisonment.
The low numbers of forced commitments to outpatient care across the state make sense, Dr. Nelson said, since the law wasn’t intended to “force a bunch of folks with typically high recidivism with mental illness into involuntary treatment.”
Instead, he said, the law has promoted a so-called black robe effect – essentially, a form of intimidation by judge.
Dr. Nelson said he has tracked the debate over forced outpatient care for years and has mixed feelings about the law.
There’s value to coaxing people with mental illness into care when they are unable to recognize their illness, he said. “But there are way too many gaps and holes for people to fall into,” he said. “They have the potential to be mistreated, poorly treated, poorly diagnosed.”
While Laura’s Law requires counties to offer comprehensive outpatient mental health care, “it’s really difficult to know whether the programs are meeting all of the conditions of the law,” Dr. Nelson said.
Still, he said, Laura’s Law is forcing counties to discuss how to care for people with mental illness who are targeted by the legislation, he said. “They are beginning to have a lively conversation about how we are going to reach out to these people and help them, even to just avoid the implementation of Laura’s Law.”
Dr. Nelson has no relevant disclosures.
EXPERT ANALYSIS FROM APA
Coping when a patient commits suicide
SAN DIEGO – Most psychiatrists raised their hands in a conference room at the annual meeting of the American Psychiatric Association when a presenter asked whether they’d ever had a patient die from suicide. Moments later, one rose and described her own devastating experience with a patient who killed himself.
“We’d talked for 100 nights over 12 years. If a call came in at night, I knew who it was,” she said. Then he committed suicide, forcing her to question her assumptions about her ability to help others.
“I had this unconscious fantasy that I could will people to keep on living,” she said.
“We spend so much time with our patients,” added another audience member, that “it’s almost like a family member dying. Just overwhelming sadness.”
A 2015 meta-analysis estimated that there is 1 suicide for every 676 inpatient admissions, and a 20-year prospective study found that 1% of 6,891 psychiatric outpatients committed suicide (Acta Psychiatr Scand. 2015 Mar;131[3]:174-84), (J Consult Clin Psychol. 2000 Jun;68[3]:371-7).
To make things more complex for psychiatrists, suicides and attempted suicides are frequent triggers for malpractice suits, accounting for 5.4% overall and 17% of those directed at psychiatrists, said psychologist and copresenter Jane Tillman, PhD, director of the Erikson Institute for Education and Research of the Austen Riggs Center in Stockbridge, Mass., and assistant clinical professor at the Yale Child Study Center in New Haven, Conn. (However, a 2014 U.S. study found that “in malpractice, psychiatry accounted for a small percentage of overall claims and settlements” (Ann Clin Psychiatry. 2014 May;26[2]:91-6).
“They spoke to me about affective experiences like feeling incredibly sad. Some felt angry and rageful,” Dr. Tillman told the APA audience. “One young therapist, a trainee, told me that her patient’s father called to tell her the patient had died by suicide. ‘After I spoke to the patient’s father,’ the therapist recalled, ‘the mother got onto the phone and screamed. I broke down and started crying. Hearing the sound of a mother who had lost her child went right through me.’ ”
Another therapist felt “angry at everyone” and guilty, too, after a patient killed herself without calling for help. And Dr. Tillman heard from therapists who worried about their professional lives, how they’d be viewed, and whether they’d be cut off from their peers.
“I had the sense of people pulling away from me and me pulling away from them,” one therapist told Dr. Tillman. “Some reached out to me early but they didn’t follow through, and I didn’t follow through.”
Young therapists face unique challenges, Dr. Tillman said. “They felt foolish, as if they’d been grandiose,” she said. “They pathologize hope.”
Copresenter Dr. Plakun, associate medical director and director of biopsychosocial advocacy at Austen Riggs, offered these tips to psychiatrists:
• Support colleagues whose patients kill themselves. “Convene and participate in a nonjudgmental review of the suicide. Be there, try to be part of this discussion, share your own experiences. And [be] aware of the inevitability of countertransference of guilt, anger, and blaming.”
• “If you are the person who had a patient die by suicide, avoid isolation; call your insurance carrier for consultation about risk management issues, and prepare yourself for contact with the family.”
• Take special care before meetings with family: Understand the confidentiality issues and remember where the focus belongs. “You’re there to meet the family’s needs, not yours primarily. There’s no reason to castigate yourself and take blame. But that doesn’t mean you can’t express genuine sorrow about the loss.”
• Seek professional support and focus on self-care. “Try to preserve a space in our families and in our personal friendships where we can continue to live our lives and not be haunted by these things in our relationships with partners, spouses, children. And we need to grieve well. It’s a terrible loss, and it’s something that we need to pay attention to and take seriously.”
Dr. Plakun and Dr. Tillman reported no relevant disclosures.
SAN DIEGO – Most psychiatrists raised their hands in a conference room at the annual meeting of the American Psychiatric Association when a presenter asked whether they’d ever had a patient die from suicide. Moments later, one rose and described her own devastating experience with a patient who killed himself.
“We’d talked for 100 nights over 12 years. If a call came in at night, I knew who it was,” she said. Then he committed suicide, forcing her to question her assumptions about her ability to help others.
“I had this unconscious fantasy that I could will people to keep on living,” she said.
“We spend so much time with our patients,” added another audience member, that “it’s almost like a family member dying. Just overwhelming sadness.”
A 2015 meta-analysis estimated that there is 1 suicide for every 676 inpatient admissions, and a 20-year prospective study found that 1% of 6,891 psychiatric outpatients committed suicide (Acta Psychiatr Scand. 2015 Mar;131[3]:174-84), (J Consult Clin Psychol. 2000 Jun;68[3]:371-7).
To make things more complex for psychiatrists, suicides and attempted suicides are frequent triggers for malpractice suits, accounting for 5.4% overall and 17% of those directed at psychiatrists, said psychologist and copresenter Jane Tillman, PhD, director of the Erikson Institute for Education and Research of the Austen Riggs Center in Stockbridge, Mass., and assistant clinical professor at the Yale Child Study Center in New Haven, Conn. (However, a 2014 U.S. study found that “in malpractice, psychiatry accounted for a small percentage of overall claims and settlements” (Ann Clin Psychiatry. 2014 May;26[2]:91-6).
“They spoke to me about affective experiences like feeling incredibly sad. Some felt angry and rageful,” Dr. Tillman told the APA audience. “One young therapist, a trainee, told me that her patient’s father called to tell her the patient had died by suicide. ‘After I spoke to the patient’s father,’ the therapist recalled, ‘the mother got onto the phone and screamed. I broke down and started crying. Hearing the sound of a mother who had lost her child went right through me.’ ”
Another therapist felt “angry at everyone” and guilty, too, after a patient killed herself without calling for help. And Dr. Tillman heard from therapists who worried about their professional lives, how they’d be viewed, and whether they’d be cut off from their peers.
“I had the sense of people pulling away from me and me pulling away from them,” one therapist told Dr. Tillman. “Some reached out to me early but they didn’t follow through, and I didn’t follow through.”
Young therapists face unique challenges, Dr. Tillman said. “They felt foolish, as if they’d been grandiose,” she said. “They pathologize hope.”
Copresenter Dr. Plakun, associate medical director and director of biopsychosocial advocacy at Austen Riggs, offered these tips to psychiatrists:
• Support colleagues whose patients kill themselves. “Convene and participate in a nonjudgmental review of the suicide. Be there, try to be part of this discussion, share your own experiences. And [be] aware of the inevitability of countertransference of guilt, anger, and blaming.”
• “If you are the person who had a patient die by suicide, avoid isolation; call your insurance carrier for consultation about risk management issues, and prepare yourself for contact with the family.”
• Take special care before meetings with family: Understand the confidentiality issues and remember where the focus belongs. “You’re there to meet the family’s needs, not yours primarily. There’s no reason to castigate yourself and take blame. But that doesn’t mean you can’t express genuine sorrow about the loss.”
• Seek professional support and focus on self-care. “Try to preserve a space in our families and in our personal friendships where we can continue to live our lives and not be haunted by these things in our relationships with partners, spouses, children. And we need to grieve well. It’s a terrible loss, and it’s something that we need to pay attention to and take seriously.”
Dr. Plakun and Dr. Tillman reported no relevant disclosures.
SAN DIEGO – Most psychiatrists raised their hands in a conference room at the annual meeting of the American Psychiatric Association when a presenter asked whether they’d ever had a patient die from suicide. Moments later, one rose and described her own devastating experience with a patient who killed himself.
“We’d talked for 100 nights over 12 years. If a call came in at night, I knew who it was,” she said. Then he committed suicide, forcing her to question her assumptions about her ability to help others.
“I had this unconscious fantasy that I could will people to keep on living,” she said.
“We spend so much time with our patients,” added another audience member, that “it’s almost like a family member dying. Just overwhelming sadness.”
A 2015 meta-analysis estimated that there is 1 suicide for every 676 inpatient admissions, and a 20-year prospective study found that 1% of 6,891 psychiatric outpatients committed suicide (Acta Psychiatr Scand. 2015 Mar;131[3]:174-84), (J Consult Clin Psychol. 2000 Jun;68[3]:371-7).
To make things more complex for psychiatrists, suicides and attempted suicides are frequent triggers for malpractice suits, accounting for 5.4% overall and 17% of those directed at psychiatrists, said psychologist and copresenter Jane Tillman, PhD, director of the Erikson Institute for Education and Research of the Austen Riggs Center in Stockbridge, Mass., and assistant clinical professor at the Yale Child Study Center in New Haven, Conn. (However, a 2014 U.S. study found that “in malpractice, psychiatry accounted for a small percentage of overall claims and settlements” (Ann Clin Psychiatry. 2014 May;26[2]:91-6).
“They spoke to me about affective experiences like feeling incredibly sad. Some felt angry and rageful,” Dr. Tillman told the APA audience. “One young therapist, a trainee, told me that her patient’s father called to tell her the patient had died by suicide. ‘After I spoke to the patient’s father,’ the therapist recalled, ‘the mother got onto the phone and screamed. I broke down and started crying. Hearing the sound of a mother who had lost her child went right through me.’ ”
Another therapist felt “angry at everyone” and guilty, too, after a patient killed herself without calling for help. And Dr. Tillman heard from therapists who worried about their professional lives, how they’d be viewed, and whether they’d be cut off from their peers.
“I had the sense of people pulling away from me and me pulling away from them,” one therapist told Dr. Tillman. “Some reached out to me early but they didn’t follow through, and I didn’t follow through.”
Young therapists face unique challenges, Dr. Tillman said. “They felt foolish, as if they’d been grandiose,” she said. “They pathologize hope.”
Copresenter Dr. Plakun, associate medical director and director of biopsychosocial advocacy at Austen Riggs, offered these tips to psychiatrists:
• Support colleagues whose patients kill themselves. “Convene and participate in a nonjudgmental review of the suicide. Be there, try to be part of this discussion, share your own experiences. And [be] aware of the inevitability of countertransference of guilt, anger, and blaming.”
• “If you are the person who had a patient die by suicide, avoid isolation; call your insurance carrier for consultation about risk management issues, and prepare yourself for contact with the family.”
• Take special care before meetings with family: Understand the confidentiality issues and remember where the focus belongs. “You’re there to meet the family’s needs, not yours primarily. There’s no reason to castigate yourself and take blame. But that doesn’t mean you can’t express genuine sorrow about the loss.”
• Seek professional support and focus on self-care. “Try to preserve a space in our families and in our personal friendships where we can continue to live our lives and not be haunted by these things in our relationships with partners, spouses, children. And we need to grieve well. It’s a terrible loss, and it’s something that we need to pay attention to and take seriously.”
Dr. Plakun and Dr. Tillman reported no relevant disclosures.
AT APA
Nearly half of patients who stop taking opioids for 6 months resume use later
SAN DIEGO – A new study of medical records offers insights into the persistence of opioid use: Most patients who were prescribed opioid painkillers did not go back for a refill right away, but nearly half of patients who stopped taking the drugs for at least 6 months ended up using them again over a 3-year period.
“This key finding indicates that programs that address opioid use need to focus on long-term support and education to ensure that individuals do not become long-term users,” psychiatrist and lead author Shareh Ghani, MD, vice president and medical director of Magellan Health Services, San Francisco, said in an interview.
Researchers also found that opioid use appeared linked to three unexpected conditions – lipid disorders, hypertension, and sleep-wake disorders – and found that more than half of those who had at least two prescriptions for high-dose opioids kept taking the drugs over 18 months after an initial 90-day period.
Dr. Ghani and his colleague, Gowri Shetty, MPH, analyzed medical and pharmacy data from 2009-2012 for 2.5 million people. The participants, aged 20-64 years, came from across the United States and were part of a commercial health plan.
The researchers found that 21% had received one prescription for an opioid. Users considered at risk for persistent use – more than one prescription over 3 years – were more likely than were nonusers to have these characteristics: spondylosis and other back problems (odds ratio, 5.3), substance-related and addictive disorders (OR, 4.6), sleep-wake disorders (OR, 2.2), depressive disorders (OR, 1.7), headaches (OR, 2.1), and anxiety disorders (OR, 1.5.) The P values for all of those characteristics were less than .001.
They also found that patients who received certain kinds of treatment were at higher risk, compared with nonusers: those who were treated for substance abuse treatment (OR, 4.5), in emergency departments (OR, 3.2), with anesthesia (OR, 4.2), for mental health issues (OR, 2.3), and with surgery (OR, 2.0). The P values for all of those characteristics also were less than .001.
“The unexpected findings were the presence of lipid disorders, hypertension, and sleep-wake disorders. These diagnoses were not found in other literature,” Dr. Ghani said in an interview. “These conditions, however, are related to others that are known. For instance, a person with knee joint pain who is overweight – a known risk factor – may also have hypertension and lipid disorders.”
The researchers also discovered that 80% of patients who received an opioid prescription did not get a refill. Of those who had at least two prescriptions and a stable dose over an initial 90 days, 14% went on to have more prescriptions and a boost in dosage over 18 months, while 12% stayed the same and almost 74% took less.
But the situation was different for those with at least two prescriptions and a high dose (more than 120 mg) over an initial 90 days: 56% of them stayed at that level over 18 months.
The researchers also found that 48% of those who had stopped using opioids for at least 6 months went on to use them again. This high rate “suggests that physicians and patients need to be aware of the high risk of dependence and addiction for some individuals,” Dr. Ghani said. “Studying prescription fill behaviors and the persistence of prescription opioid users helps identify individuals at high risk for persistent use and may provide a better understanding of how to target interventions for inappropriate opioid use.”
The study has limitations. It does not indicate whether patients became substance abusers, nor does it provide details about opioids obtained illegally. Still, “we do know from literature and clinical experience that staying on prescription opioids may lead to dependence, escalation of dose, and increased risk of developing addictions that can lead to using street drugs like heroin,” Dr. Ghani said.
Magellan funded the study. Dr. Ghani reported no additional disclosures.
SAN DIEGO – A new study of medical records offers insights into the persistence of opioid use: Most patients who were prescribed opioid painkillers did not go back for a refill right away, but nearly half of patients who stopped taking the drugs for at least 6 months ended up using them again over a 3-year period.
“This key finding indicates that programs that address opioid use need to focus on long-term support and education to ensure that individuals do not become long-term users,” psychiatrist and lead author Shareh Ghani, MD, vice president and medical director of Magellan Health Services, San Francisco, said in an interview.
Researchers also found that opioid use appeared linked to three unexpected conditions – lipid disorders, hypertension, and sleep-wake disorders – and found that more than half of those who had at least two prescriptions for high-dose opioids kept taking the drugs over 18 months after an initial 90-day period.
Dr. Ghani and his colleague, Gowri Shetty, MPH, analyzed medical and pharmacy data from 2009-2012 for 2.5 million people. The participants, aged 20-64 years, came from across the United States and were part of a commercial health plan.
The researchers found that 21% had received one prescription for an opioid. Users considered at risk for persistent use – more than one prescription over 3 years – were more likely than were nonusers to have these characteristics: spondylosis and other back problems (odds ratio, 5.3), substance-related and addictive disorders (OR, 4.6), sleep-wake disorders (OR, 2.2), depressive disorders (OR, 1.7), headaches (OR, 2.1), and anxiety disorders (OR, 1.5.) The P values for all of those characteristics were less than .001.
They also found that patients who received certain kinds of treatment were at higher risk, compared with nonusers: those who were treated for substance abuse treatment (OR, 4.5), in emergency departments (OR, 3.2), with anesthesia (OR, 4.2), for mental health issues (OR, 2.3), and with surgery (OR, 2.0). The P values for all of those characteristics also were less than .001.
“The unexpected findings were the presence of lipid disorders, hypertension, and sleep-wake disorders. These diagnoses were not found in other literature,” Dr. Ghani said in an interview. “These conditions, however, are related to others that are known. For instance, a person with knee joint pain who is overweight – a known risk factor – may also have hypertension and lipid disorders.”
The researchers also discovered that 80% of patients who received an opioid prescription did not get a refill. Of those who had at least two prescriptions and a stable dose over an initial 90 days, 14% went on to have more prescriptions and a boost in dosage over 18 months, while 12% stayed the same and almost 74% took less.
But the situation was different for those with at least two prescriptions and a high dose (more than 120 mg) over an initial 90 days: 56% of them stayed at that level over 18 months.
The researchers also found that 48% of those who had stopped using opioids for at least 6 months went on to use them again. This high rate “suggests that physicians and patients need to be aware of the high risk of dependence and addiction for some individuals,” Dr. Ghani said. “Studying prescription fill behaviors and the persistence of prescription opioid users helps identify individuals at high risk for persistent use and may provide a better understanding of how to target interventions for inappropriate opioid use.”
The study has limitations. It does not indicate whether patients became substance abusers, nor does it provide details about opioids obtained illegally. Still, “we do know from literature and clinical experience that staying on prescription opioids may lead to dependence, escalation of dose, and increased risk of developing addictions that can lead to using street drugs like heroin,” Dr. Ghani said.
Magellan funded the study. Dr. Ghani reported no additional disclosures.
SAN DIEGO – A new study of medical records offers insights into the persistence of opioid use: Most patients who were prescribed opioid painkillers did not go back for a refill right away, but nearly half of patients who stopped taking the drugs for at least 6 months ended up using them again over a 3-year period.
“This key finding indicates that programs that address opioid use need to focus on long-term support and education to ensure that individuals do not become long-term users,” psychiatrist and lead author Shareh Ghani, MD, vice president and medical director of Magellan Health Services, San Francisco, said in an interview.
Researchers also found that opioid use appeared linked to three unexpected conditions – lipid disorders, hypertension, and sleep-wake disorders – and found that more than half of those who had at least two prescriptions for high-dose opioids kept taking the drugs over 18 months after an initial 90-day period.
Dr. Ghani and his colleague, Gowri Shetty, MPH, analyzed medical and pharmacy data from 2009-2012 for 2.5 million people. The participants, aged 20-64 years, came from across the United States and were part of a commercial health plan.
The researchers found that 21% had received one prescription for an opioid. Users considered at risk for persistent use – more than one prescription over 3 years – were more likely than were nonusers to have these characteristics: spondylosis and other back problems (odds ratio, 5.3), substance-related and addictive disorders (OR, 4.6), sleep-wake disorders (OR, 2.2), depressive disorders (OR, 1.7), headaches (OR, 2.1), and anxiety disorders (OR, 1.5.) The P values for all of those characteristics were less than .001.
They also found that patients who received certain kinds of treatment were at higher risk, compared with nonusers: those who were treated for substance abuse treatment (OR, 4.5), in emergency departments (OR, 3.2), with anesthesia (OR, 4.2), for mental health issues (OR, 2.3), and with surgery (OR, 2.0). The P values for all of those characteristics also were less than .001.
“The unexpected findings were the presence of lipid disorders, hypertension, and sleep-wake disorders. These diagnoses were not found in other literature,” Dr. Ghani said in an interview. “These conditions, however, are related to others that are known. For instance, a person with knee joint pain who is overweight – a known risk factor – may also have hypertension and lipid disorders.”
The researchers also discovered that 80% of patients who received an opioid prescription did not get a refill. Of those who had at least two prescriptions and a stable dose over an initial 90 days, 14% went on to have more prescriptions and a boost in dosage over 18 months, while 12% stayed the same and almost 74% took less.
But the situation was different for those with at least two prescriptions and a high dose (more than 120 mg) over an initial 90 days: 56% of them stayed at that level over 18 months.
The researchers also found that 48% of those who had stopped using opioids for at least 6 months went on to use them again. This high rate “suggests that physicians and patients need to be aware of the high risk of dependence and addiction for some individuals,” Dr. Ghani said. “Studying prescription fill behaviors and the persistence of prescription opioid users helps identify individuals at high risk for persistent use and may provide a better understanding of how to target interventions for inappropriate opioid use.”
The study has limitations. It does not indicate whether patients became substance abusers, nor does it provide details about opioids obtained illegally. Still, “we do know from literature and clinical experience that staying on prescription opioids may lead to dependence, escalation of dose, and increased risk of developing addictions that can lead to using street drugs like heroin,” Dr. Ghani said.
Magellan funded the study. Dr. Ghani reported no additional disclosures.
AT APA
Key clinical point:
Major finding: Forty-eight percent of patients who had stopped using opioids for at least 6 months went on to use them again.
Data source: An analysis of medical and pharmacy data from 2009-2012 for 2.5 million people aged 20-64 who were part of a commercial health plan.
Disclosures: Dr. Ghani is vice president and medical director of Magellan Health Services, which funded the study.
Involuntary commitment sought in 5% of anorexia admissions
SAN DIEGO – Court orders were sought to force 5% of patients admitted for anorexia nervosa disorders to remain involuntarily under hospital care, according to findings from a 4-year study of patients treated at a Colorado clinic.
Nearly all of the patients declined to fight those efforts. However, the orders were withdrawn in about one-quarter of cases because treatment was deemed to be futile.
The study findings point to the importance of seeking civil commitment early in the course of illness in patients with anorexia nervosa when it can do the most good, study author Patricia Westmoreland, MD, attending psychiatrist at the Eating Recovery Center in Denver, said in an interview.
Dr. Westmoreland presented the findings at the annual meeting of the American Psychiatric Association, where she contended that anorexia nervosa has the highest mortality of any psychiatric disorder. “If patients are not treated earlier in the course of their illness and when they’re at a younger age,” she said, “they develop severe and enduring eating disorders.”
Anorexia nervosa is estimated to have a prevalence rate of 0.3% in young women. Research suggests that 20% of people with the disease kill themselves (Int J Eat Disord. 2003 Dec;34[4]:383-96), (Arch Gen Psychiatry. 2011;68[7]:724-31).
For the new study, Dr. Westmoreland and her colleagues tracked 2,106 admissions of patients who were treated for two conditions – anorexia nervosa restricting subtype and anorexia nervosa binge purge subtype – at the Eating Recovery Center from April 2012 to March 2016. The ages and genders of the subjects were not available.
Officials sought involuntary care in 109, or 5.2%, of the admissions, including 11 patients who were recommitted at least once.
Of the 109 admissions:
• 85% waived the right to a hearing (94% of those who fought commitment ultimately were committed involuntarily).
• 31% successfully completed treatment.
• 24% had their commitments – also known as certifications – terminated because treatment appeared to be futile.
“These are patients for whom certification is only helpful to a point, beyond which it becomes harmful, i.e., patients harming themselves to leave a locked facility, patients pulling out NG tubes so many times they cause injury, patients who purge continuously despite being tube fed,” Dr. Westmoreland said in an interview. “In other cases, the team evaluated the patient and determined he or she is, in general, being harmed more than helped by trying to attain goal weight. This is where harm reduction may prove useful. And failing that, palliative or hospice care for a patient who has had many treatments over the years and has never recovered for any meaningful period of time.”
Dr. Westmoreland defined harm reduction in this context as “having patient being managed at an agreed-upon weight that is lower than an ideal body weight, but nonetheless a weight at which they can function and have some quality of life, even if that quality of life is not optimal.”
This also means that the patient must regularly check with an outpatient treatment team – dietitian, psychiatrist, and therapist – and be monitored for signs of unacceptable levels of weight loss or abnormal lab results, she said. These problems, she added, will trigger hospitalization.
Dr. Westmoreland reported no relevant disclosures.
SAN DIEGO – Court orders were sought to force 5% of patients admitted for anorexia nervosa disorders to remain involuntarily under hospital care, according to findings from a 4-year study of patients treated at a Colorado clinic.
Nearly all of the patients declined to fight those efforts. However, the orders were withdrawn in about one-quarter of cases because treatment was deemed to be futile.
The study findings point to the importance of seeking civil commitment early in the course of illness in patients with anorexia nervosa when it can do the most good, study author Patricia Westmoreland, MD, attending psychiatrist at the Eating Recovery Center in Denver, said in an interview.
Dr. Westmoreland presented the findings at the annual meeting of the American Psychiatric Association, where she contended that anorexia nervosa has the highest mortality of any psychiatric disorder. “If patients are not treated earlier in the course of their illness and when they’re at a younger age,” she said, “they develop severe and enduring eating disorders.”
Anorexia nervosa is estimated to have a prevalence rate of 0.3% in young women. Research suggests that 20% of people with the disease kill themselves (Int J Eat Disord. 2003 Dec;34[4]:383-96), (Arch Gen Psychiatry. 2011;68[7]:724-31).
For the new study, Dr. Westmoreland and her colleagues tracked 2,106 admissions of patients who were treated for two conditions – anorexia nervosa restricting subtype and anorexia nervosa binge purge subtype – at the Eating Recovery Center from April 2012 to March 2016. The ages and genders of the subjects were not available.
Officials sought involuntary care in 109, or 5.2%, of the admissions, including 11 patients who were recommitted at least once.
Of the 109 admissions:
• 85% waived the right to a hearing (94% of those who fought commitment ultimately were committed involuntarily).
• 31% successfully completed treatment.
• 24% had their commitments – also known as certifications – terminated because treatment appeared to be futile.
“These are patients for whom certification is only helpful to a point, beyond which it becomes harmful, i.e., patients harming themselves to leave a locked facility, patients pulling out NG tubes so many times they cause injury, patients who purge continuously despite being tube fed,” Dr. Westmoreland said in an interview. “In other cases, the team evaluated the patient and determined he or she is, in general, being harmed more than helped by trying to attain goal weight. This is where harm reduction may prove useful. And failing that, palliative or hospice care for a patient who has had many treatments over the years and has never recovered for any meaningful period of time.”
Dr. Westmoreland defined harm reduction in this context as “having patient being managed at an agreed-upon weight that is lower than an ideal body weight, but nonetheless a weight at which they can function and have some quality of life, even if that quality of life is not optimal.”
This also means that the patient must regularly check with an outpatient treatment team – dietitian, psychiatrist, and therapist – and be monitored for signs of unacceptable levels of weight loss or abnormal lab results, she said. These problems, she added, will trigger hospitalization.
Dr. Westmoreland reported no relevant disclosures.
SAN DIEGO – Court orders were sought to force 5% of patients admitted for anorexia nervosa disorders to remain involuntarily under hospital care, according to findings from a 4-year study of patients treated at a Colorado clinic.
Nearly all of the patients declined to fight those efforts. However, the orders were withdrawn in about one-quarter of cases because treatment was deemed to be futile.
The study findings point to the importance of seeking civil commitment early in the course of illness in patients with anorexia nervosa when it can do the most good, study author Patricia Westmoreland, MD, attending psychiatrist at the Eating Recovery Center in Denver, said in an interview.
Dr. Westmoreland presented the findings at the annual meeting of the American Psychiatric Association, where she contended that anorexia nervosa has the highest mortality of any psychiatric disorder. “If patients are not treated earlier in the course of their illness and when they’re at a younger age,” she said, “they develop severe and enduring eating disorders.”
Anorexia nervosa is estimated to have a prevalence rate of 0.3% in young women. Research suggests that 20% of people with the disease kill themselves (Int J Eat Disord. 2003 Dec;34[4]:383-96), (Arch Gen Psychiatry. 2011;68[7]:724-31).
For the new study, Dr. Westmoreland and her colleagues tracked 2,106 admissions of patients who were treated for two conditions – anorexia nervosa restricting subtype and anorexia nervosa binge purge subtype – at the Eating Recovery Center from April 2012 to March 2016. The ages and genders of the subjects were not available.
Officials sought involuntary care in 109, or 5.2%, of the admissions, including 11 patients who were recommitted at least once.
Of the 109 admissions:
• 85% waived the right to a hearing (94% of those who fought commitment ultimately were committed involuntarily).
• 31% successfully completed treatment.
• 24% had their commitments – also known as certifications – terminated because treatment appeared to be futile.
“These are patients for whom certification is only helpful to a point, beyond which it becomes harmful, i.e., patients harming themselves to leave a locked facility, patients pulling out NG tubes so many times they cause injury, patients who purge continuously despite being tube fed,” Dr. Westmoreland said in an interview. “In other cases, the team evaluated the patient and determined he or she is, in general, being harmed more than helped by trying to attain goal weight. This is where harm reduction may prove useful. And failing that, palliative or hospice care for a patient who has had many treatments over the years and has never recovered for any meaningful period of time.”
Dr. Westmoreland defined harm reduction in this context as “having patient being managed at an agreed-upon weight that is lower than an ideal body weight, but nonetheless a weight at which they can function and have some quality of life, even if that quality of life is not optimal.”
This also means that the patient must regularly check with an outpatient treatment team – dietitian, psychiatrist, and therapist – and be monitored for signs of unacceptable levels of weight loss or abnormal lab results, she said. These problems, she added, will trigger hospitalization.
Dr. Westmoreland reported no relevant disclosures.
AT APA
As designer drugs multiply, toxicologists spring into action
SAN DIEGO – Forensic toxicologist Donna Papsun spends her days with drugs, but she doesn’t see patients or try to make anyone better. Still, her work is crucial to every medical professional who needs to know which new illicit drugs their patients have been taking.
In Willow Grove, Pa., a suburb of Philadelphia, Ms. Papsun and her colleagues at NMS Labs develop screening tests for designer drugs that have just appeared on the black market or crossed the Drug Enforcement Administration’s (DEA) radar.
As Ms. Papsun told an audience at the annual meeting of the American Psychiatric Association, she faced a unique obstacle last summer, when an elephant tranquilizer called carfentanil, a derivative of fentanyl, began to make headlines. The obstacle? The U.S.-Canada border.
She wanted to develop a test for the opioid but couldn’t start until she got a reference sample of the controlled substance from carfentanil’s only manufacturer, a firm in Canada. It took months. “Crossing an international border caused all sorts of problems,” she said.
New designer drugs are constantly hitting the market. They’re often especially appealing – and especially risky – because routine drug tests can’t detect them, at least not yet.
In an interview, Ms. Papsun talked about the challenges of trying to keep up with the drug makers – and users.
“Designer drug testing developed back in 2008 will not catch anything that is seen in today’s designer drug market,” she said. “Designer drug testing requires constant attention, assessment, resources, and updating.”
Question: How long does it typically take to create a test for a new strain of illicit drug?
Answer: This can take anywhere from 3 to 9 months, and potentially longer, and it depends on many factors. Once a new drug has hit the market, we check to see if there is certified reference material available. If there is, then we can start to develop a test. Development includes identifying a successful chemical extraction technique – isolating the drug in question from biological matrix such as blood or urine – as well as a platform that reliably detects the drug without falsely reporting positives.
After development, the test has to go through a process called validation, which is a series of experiments to prove that the developed method works rigorously, day after day, and provides the same results. This is very important in forensic toxicology, because our results may be involved in criminal and civil litigation and must stand up to the rigors of court.
Q: What are some examples of the types of drugs that you’ve had to develop tests for?
A: Just in the past year, we have developed tests for new designer opioids (including carfentanil, furanylfentanyl, acrylfentanyl, and U-47700), designer benzodiazepines (including etizolam, diclazepam, flubromazolam, and flubromazepam) and new designer stimulants (including n-ethyl pentylone and dibutylone).
We have a synthetic cannabinoid test that was developed for the first time back in 2010. That test has been redeveloped several times since then, because we constantly have to update the test to keep up with the rapid changes in market availability of substances.
Q: What are some of the challenges that you face in terms of getting samples of human fluids that you can test for the drugs?
A: Most of the samples we see are from either death investigation cases or driving-under-the-influence cases. Samples from intoxications at hospitals are important, because those data help [us] understand the concentrations of drugs at which people can survive. But often, if the patients survive, their biological specimens are not forwarded for specialized toxicology testing. Most hospital systems do not have the analytical capabilities to detect designer drugs, and most lack the resources to seek out the causal agent for an intoxication or apparent overdose.
Q: At the APA meeting, you talked about the risk that you’ll hear about a strain from the DEA, develop a test and find out it’s obsolete because the drug isn’t used anymore. Does that happen very often?
A: Yes. The problem with designer drugs is that there are so many, so you can spend a lot of time, money, and other resources dedicated to developing and validating a test for a drug that may or may not even be popular.
As a business, you have to make decisions regarding prioritization: Do we build a test for a drug that has only been reported once, or do we focus our efforts on a substance that has been reported dozens of times?
We certainly have spent time and resources developing a test that became obsolete, or never reported a positive case. For example, we developed a test for desomorphine, and we have never chemically confirmed desomorphine in a biological specimen. It definitely is hit or miss, but we spend a lot of time and research a lot of different avenues to make educated decisions regarding the substances we develop tests for.
SAN DIEGO – Forensic toxicologist Donna Papsun spends her days with drugs, but she doesn’t see patients or try to make anyone better. Still, her work is crucial to every medical professional who needs to know which new illicit drugs their patients have been taking.
In Willow Grove, Pa., a suburb of Philadelphia, Ms. Papsun and her colleagues at NMS Labs develop screening tests for designer drugs that have just appeared on the black market or crossed the Drug Enforcement Administration’s (DEA) radar.
As Ms. Papsun told an audience at the annual meeting of the American Psychiatric Association, she faced a unique obstacle last summer, when an elephant tranquilizer called carfentanil, a derivative of fentanyl, began to make headlines. The obstacle? The U.S.-Canada border.
She wanted to develop a test for the opioid but couldn’t start until she got a reference sample of the controlled substance from carfentanil’s only manufacturer, a firm in Canada. It took months. “Crossing an international border caused all sorts of problems,” she said.
New designer drugs are constantly hitting the market. They’re often especially appealing – and especially risky – because routine drug tests can’t detect them, at least not yet.
In an interview, Ms. Papsun talked about the challenges of trying to keep up with the drug makers – and users.
“Designer drug testing developed back in 2008 will not catch anything that is seen in today’s designer drug market,” she said. “Designer drug testing requires constant attention, assessment, resources, and updating.”
Question: How long does it typically take to create a test for a new strain of illicit drug?
Answer: This can take anywhere from 3 to 9 months, and potentially longer, and it depends on many factors. Once a new drug has hit the market, we check to see if there is certified reference material available. If there is, then we can start to develop a test. Development includes identifying a successful chemical extraction technique – isolating the drug in question from biological matrix such as blood or urine – as well as a platform that reliably detects the drug without falsely reporting positives.
After development, the test has to go through a process called validation, which is a series of experiments to prove that the developed method works rigorously, day after day, and provides the same results. This is very important in forensic toxicology, because our results may be involved in criminal and civil litigation and must stand up to the rigors of court.
Q: What are some examples of the types of drugs that you’ve had to develop tests for?
A: Just in the past year, we have developed tests for new designer opioids (including carfentanil, furanylfentanyl, acrylfentanyl, and U-47700), designer benzodiazepines (including etizolam, diclazepam, flubromazolam, and flubromazepam) and new designer stimulants (including n-ethyl pentylone and dibutylone).
We have a synthetic cannabinoid test that was developed for the first time back in 2010. That test has been redeveloped several times since then, because we constantly have to update the test to keep up with the rapid changes in market availability of substances.
Q: What are some of the challenges that you face in terms of getting samples of human fluids that you can test for the drugs?
A: Most of the samples we see are from either death investigation cases or driving-under-the-influence cases. Samples from intoxications at hospitals are important, because those data help [us] understand the concentrations of drugs at which people can survive. But often, if the patients survive, their biological specimens are not forwarded for specialized toxicology testing. Most hospital systems do not have the analytical capabilities to detect designer drugs, and most lack the resources to seek out the causal agent for an intoxication or apparent overdose.
Q: At the APA meeting, you talked about the risk that you’ll hear about a strain from the DEA, develop a test and find out it’s obsolete because the drug isn’t used anymore. Does that happen very often?
A: Yes. The problem with designer drugs is that there are so many, so you can spend a lot of time, money, and other resources dedicated to developing and validating a test for a drug that may or may not even be popular.
As a business, you have to make decisions regarding prioritization: Do we build a test for a drug that has only been reported once, or do we focus our efforts on a substance that has been reported dozens of times?
We certainly have spent time and resources developing a test that became obsolete, or never reported a positive case. For example, we developed a test for desomorphine, and we have never chemically confirmed desomorphine in a biological specimen. It definitely is hit or miss, but we spend a lot of time and research a lot of different avenues to make educated decisions regarding the substances we develop tests for.
SAN DIEGO – Forensic toxicologist Donna Papsun spends her days with drugs, but she doesn’t see patients or try to make anyone better. Still, her work is crucial to every medical professional who needs to know which new illicit drugs their patients have been taking.
In Willow Grove, Pa., a suburb of Philadelphia, Ms. Papsun and her colleagues at NMS Labs develop screening tests for designer drugs that have just appeared on the black market or crossed the Drug Enforcement Administration’s (DEA) radar.
As Ms. Papsun told an audience at the annual meeting of the American Psychiatric Association, she faced a unique obstacle last summer, when an elephant tranquilizer called carfentanil, a derivative of fentanyl, began to make headlines. The obstacle? The U.S.-Canada border.
She wanted to develop a test for the opioid but couldn’t start until she got a reference sample of the controlled substance from carfentanil’s only manufacturer, a firm in Canada. It took months. “Crossing an international border caused all sorts of problems,” she said.
New designer drugs are constantly hitting the market. They’re often especially appealing – and especially risky – because routine drug tests can’t detect them, at least not yet.
In an interview, Ms. Papsun talked about the challenges of trying to keep up with the drug makers – and users.
“Designer drug testing developed back in 2008 will not catch anything that is seen in today’s designer drug market,” she said. “Designer drug testing requires constant attention, assessment, resources, and updating.”
Question: How long does it typically take to create a test for a new strain of illicit drug?
Answer: This can take anywhere from 3 to 9 months, and potentially longer, and it depends on many factors. Once a new drug has hit the market, we check to see if there is certified reference material available. If there is, then we can start to develop a test. Development includes identifying a successful chemical extraction technique – isolating the drug in question from biological matrix such as blood or urine – as well as a platform that reliably detects the drug without falsely reporting positives.
After development, the test has to go through a process called validation, which is a series of experiments to prove that the developed method works rigorously, day after day, and provides the same results. This is very important in forensic toxicology, because our results may be involved in criminal and civil litigation and must stand up to the rigors of court.
Q: What are some examples of the types of drugs that you’ve had to develop tests for?
A: Just in the past year, we have developed tests for new designer opioids (including carfentanil, furanylfentanyl, acrylfentanyl, and U-47700), designer benzodiazepines (including etizolam, diclazepam, flubromazolam, and flubromazepam) and new designer stimulants (including n-ethyl pentylone and dibutylone).
We have a synthetic cannabinoid test that was developed for the first time back in 2010. That test has been redeveloped several times since then, because we constantly have to update the test to keep up with the rapid changes in market availability of substances.
Q: What are some of the challenges that you face in terms of getting samples of human fluids that you can test for the drugs?
A: Most of the samples we see are from either death investigation cases or driving-under-the-influence cases. Samples from intoxications at hospitals are important, because those data help [us] understand the concentrations of drugs at which people can survive. But often, if the patients survive, their biological specimens are not forwarded for specialized toxicology testing. Most hospital systems do not have the analytical capabilities to detect designer drugs, and most lack the resources to seek out the causal agent for an intoxication or apparent overdose.
Q: At the APA meeting, you talked about the risk that you’ll hear about a strain from the DEA, develop a test and find out it’s obsolete because the drug isn’t used anymore. Does that happen very often?
A: Yes. The problem with designer drugs is that there are so many, so you can spend a lot of time, money, and other resources dedicated to developing and validating a test for a drug that may or may not even be popular.
As a business, you have to make decisions regarding prioritization: Do we build a test for a drug that has only been reported once, or do we focus our efforts on a substance that has been reported dozens of times?
We certainly have spent time and resources developing a test that became obsolete, or never reported a positive case. For example, we developed a test for desomorphine, and we have never chemically confirmed desomorphine in a biological specimen. It definitely is hit or miss, but we spend a lot of time and research a lot of different avenues to make educated decisions regarding the substances we develop tests for.
EXPERT ANALYSIS FROM APA
Arab Americans reluctant to seek depression care from psychiatrists
SAN DIEGO – A new study, the first of its kind, finds that Arab Americans in a Michigan community are among least likely ethnic groups to seek help for depression from a mental health specialist. But they’re especially likely to look for assistance from a primary care physician.
Researchers aren’t sure why the discrepancy exists. “This may be because of the stigma associated with mental health in the community,” study lead author Florence J. Dallo, PhD, said in an interview. Whatever the case, she said, the finding points to the importance of paying close attention to the diagnosis and treatment of depression in Arab Americans.
Dr. Dallo presented her findings in an oral presentation at the annual meeting of the American Psychiatric Association. She told colleagues that Arab Americans are “largely invisible in health research.”
According to her, the sparse studies that do exist look at depression and posttraumatic stress disorder among Arab American refugees. But simply being Arab in the United States has its own challenges. “Let’s not forget the political climate in which we live, with a lot of discrimination, stress, and marginalization for this group,” Dr. Dallo said.
For the new study, she and her colleagues tracked a sample of patients who sought care at a large metropolitan hospital in southeast Michigan. This region of the country has a high Arab American population.
The researchers found that Arab Americans were less likely to complete a depression screening questionnaire than were whites, Asian Americans, African Americans, and Latinos.
Of those who did complete the questionnaire, 6.3% of Arab Americans screened positive for depression, compared with 5.6% of whites, 6.3% of African Americans, 7.7% of Latinos and 2.1% of Asian Americans.
Compared with the other ethnic groups, Arab Americans were especially likely to seek help from primary care physicians but especially unlikely to look to mental health specialists.
Why does this gap exist? In addition to the stigma surrounding mental illness in the community, Dr. Dallo said, religion might play a factor. “Arab Americans may feel their mental health condition is the will of God and that God will take care of them,” she said. “They may feel they do not need a psychiatrist or medication to help them manage their mental health condition.”
In an interview, Hikmet Jamil, MD, PhD, professor in the department of family medicine at Michigan State University, East Lansing, said there is a stigma surrounding mental health among Arab immigrants. “They don’t want to hear about psychiatry or psychology, because back home, if a person goes to a psychologist, he is a mad man,” he said. “They find it very hard to take advice from psychiatrists.”
But they still have a need for care, he said, because many suffer from PTSD and anxiety.
In some cases, this is tied to trauma suffered before they came to the United States, he said. However, “when they come here, they face another kind of trauma. They feel that there is discrimination against them, especially in terms of finding a job.”
According to Dr. Jamil, highly educated Arabs often face special challenges in finding jobs because their educational background does not always open doors in the United States – where they must take exams to get licenses. If they can’t get jobs in their chosen fields, he said, “they’ll take any kind of work to get money.”
How can clinicians serve this population? One approach is to cloak the fact that a patient is getting care for a mental issue. “They may go for primary health care but not mention depression or psychiatry,” Dr. Jamil said. “The physician can pick up on that and sometimes give them psychiatric advice without making it clear that they have some depression or psychiatric disorder.”
Dr. Dallo suggests a focus on primary care. “Given that Arab Americans are more likely to follow up with a primary care doctor rather than a behavioral specialist, perhaps the relationship with the primary care doctor can be encouraged and become regular,” she said. “The more comfortable the patient becomes with his or her primary care doctor, the more they may be more likely to see a behavioral specialist in the future.”
The study was funded by a grant from the Blue Cross Blue Shield of Michigan Foundation. Dr. Dallo and Dr. Jamil report no relevant disclosures.
SAN DIEGO – A new study, the first of its kind, finds that Arab Americans in a Michigan community are among least likely ethnic groups to seek help for depression from a mental health specialist. But they’re especially likely to look for assistance from a primary care physician.
Researchers aren’t sure why the discrepancy exists. “This may be because of the stigma associated with mental health in the community,” study lead author Florence J. Dallo, PhD, said in an interview. Whatever the case, she said, the finding points to the importance of paying close attention to the diagnosis and treatment of depression in Arab Americans.
Dr. Dallo presented her findings in an oral presentation at the annual meeting of the American Psychiatric Association. She told colleagues that Arab Americans are “largely invisible in health research.”
According to her, the sparse studies that do exist look at depression and posttraumatic stress disorder among Arab American refugees. But simply being Arab in the United States has its own challenges. “Let’s not forget the political climate in which we live, with a lot of discrimination, stress, and marginalization for this group,” Dr. Dallo said.
For the new study, she and her colleagues tracked a sample of patients who sought care at a large metropolitan hospital in southeast Michigan. This region of the country has a high Arab American population.
The researchers found that Arab Americans were less likely to complete a depression screening questionnaire than were whites, Asian Americans, African Americans, and Latinos.
Of those who did complete the questionnaire, 6.3% of Arab Americans screened positive for depression, compared with 5.6% of whites, 6.3% of African Americans, 7.7% of Latinos and 2.1% of Asian Americans.
Compared with the other ethnic groups, Arab Americans were especially likely to seek help from primary care physicians but especially unlikely to look to mental health specialists.
Why does this gap exist? In addition to the stigma surrounding mental illness in the community, Dr. Dallo said, religion might play a factor. “Arab Americans may feel their mental health condition is the will of God and that God will take care of them,” she said. “They may feel they do not need a psychiatrist or medication to help them manage their mental health condition.”
In an interview, Hikmet Jamil, MD, PhD, professor in the department of family medicine at Michigan State University, East Lansing, said there is a stigma surrounding mental health among Arab immigrants. “They don’t want to hear about psychiatry or psychology, because back home, if a person goes to a psychologist, he is a mad man,” he said. “They find it very hard to take advice from psychiatrists.”
But they still have a need for care, he said, because many suffer from PTSD and anxiety.
In some cases, this is tied to trauma suffered before they came to the United States, he said. However, “when they come here, they face another kind of trauma. They feel that there is discrimination against them, especially in terms of finding a job.”
According to Dr. Jamil, highly educated Arabs often face special challenges in finding jobs because their educational background does not always open doors in the United States – where they must take exams to get licenses. If they can’t get jobs in their chosen fields, he said, “they’ll take any kind of work to get money.”
How can clinicians serve this population? One approach is to cloak the fact that a patient is getting care for a mental issue. “They may go for primary health care but not mention depression or psychiatry,” Dr. Jamil said. “The physician can pick up on that and sometimes give them psychiatric advice without making it clear that they have some depression or psychiatric disorder.”
Dr. Dallo suggests a focus on primary care. “Given that Arab Americans are more likely to follow up with a primary care doctor rather than a behavioral specialist, perhaps the relationship with the primary care doctor can be encouraged and become regular,” she said. “The more comfortable the patient becomes with his or her primary care doctor, the more they may be more likely to see a behavioral specialist in the future.”
The study was funded by a grant from the Blue Cross Blue Shield of Michigan Foundation. Dr. Dallo and Dr. Jamil report no relevant disclosures.
SAN DIEGO – A new study, the first of its kind, finds that Arab Americans in a Michigan community are among least likely ethnic groups to seek help for depression from a mental health specialist. But they’re especially likely to look for assistance from a primary care physician.
Researchers aren’t sure why the discrepancy exists. “This may be because of the stigma associated with mental health in the community,” study lead author Florence J. Dallo, PhD, said in an interview. Whatever the case, she said, the finding points to the importance of paying close attention to the diagnosis and treatment of depression in Arab Americans.
Dr. Dallo presented her findings in an oral presentation at the annual meeting of the American Psychiatric Association. She told colleagues that Arab Americans are “largely invisible in health research.”
According to her, the sparse studies that do exist look at depression and posttraumatic stress disorder among Arab American refugees. But simply being Arab in the United States has its own challenges. “Let’s not forget the political climate in which we live, with a lot of discrimination, stress, and marginalization for this group,” Dr. Dallo said.
For the new study, she and her colleagues tracked a sample of patients who sought care at a large metropolitan hospital in southeast Michigan. This region of the country has a high Arab American population.
The researchers found that Arab Americans were less likely to complete a depression screening questionnaire than were whites, Asian Americans, African Americans, and Latinos.
Of those who did complete the questionnaire, 6.3% of Arab Americans screened positive for depression, compared with 5.6% of whites, 6.3% of African Americans, 7.7% of Latinos and 2.1% of Asian Americans.
Compared with the other ethnic groups, Arab Americans were especially likely to seek help from primary care physicians but especially unlikely to look to mental health specialists.
Why does this gap exist? In addition to the stigma surrounding mental illness in the community, Dr. Dallo said, religion might play a factor. “Arab Americans may feel their mental health condition is the will of God and that God will take care of them,” she said. “They may feel they do not need a psychiatrist or medication to help them manage their mental health condition.”
In an interview, Hikmet Jamil, MD, PhD, professor in the department of family medicine at Michigan State University, East Lansing, said there is a stigma surrounding mental health among Arab immigrants. “They don’t want to hear about psychiatry or psychology, because back home, if a person goes to a psychologist, he is a mad man,” he said. “They find it very hard to take advice from psychiatrists.”
But they still have a need for care, he said, because many suffer from PTSD and anxiety.
In some cases, this is tied to trauma suffered before they came to the United States, he said. However, “when they come here, they face another kind of trauma. They feel that there is discrimination against them, especially in terms of finding a job.”
According to Dr. Jamil, highly educated Arabs often face special challenges in finding jobs because their educational background does not always open doors in the United States – where they must take exams to get licenses. If they can’t get jobs in their chosen fields, he said, “they’ll take any kind of work to get money.”
How can clinicians serve this population? One approach is to cloak the fact that a patient is getting care for a mental issue. “They may go for primary health care but not mention depression or psychiatry,” Dr. Jamil said. “The physician can pick up on that and sometimes give them psychiatric advice without making it clear that they have some depression or psychiatric disorder.”
Dr. Dallo suggests a focus on primary care. “Given that Arab Americans are more likely to follow up with a primary care doctor rather than a behavioral specialist, perhaps the relationship with the primary care doctor can be encouraged and become regular,” she said. “The more comfortable the patient becomes with his or her primary care doctor, the more they may be more likely to see a behavioral specialist in the future.”
The study was funded by a grant from the Blue Cross Blue Shield of Michigan Foundation. Dr. Dallo and Dr. Jamil report no relevant disclosures.
EXPERT ANALYSIS FROM APA
Most veterans with schizophrenia or bipolar I report suicide attempts
SAN DIEGO – A new study reports that about half of assessed U.S. veterans with schizophrenia or bipolar I disorder have tried to kill themselves. Nearly 70% of those with schizophrenia had documented suicidal behavior or ideation, as did more than 82% of those with bipolar I disorder.
“The VA struggles to predict suicidal ideation and behavior,” said study lead author Philip D. Harvey, PhD, of the Carter VA Medical Center in Miami, in an interview. “These data suggest that having one of these diagnoses is a major risk factor. Regular assessment makes considerable sense.”
Dr. Harvey released the study findings in a poster at the annual meeting of the American Psychiatric Association.
For the study, Dr. Harvey and his colleagues examined findings from a VA research project into the genetics behind functional disability in schizophrenia and bipolar illness.
“We know that suicide risk is higher in veterans than in the general population. We also know that the current focus is on returning veterans who were deployed in combat operations,” said Dr. Harvey, who also is affiliated with the University of Miami. “We wanted to evaluate the risk for suicidal ideation and behavior in the segment of the veteran population who have recently or ever been exposed to military trauma.”
The project assessed VA patients with schizophrenia (N = 3,941) or bipolar I disorder (N = 5,414) through in-person evaluations regarding issues like cognitive and functional status, and history of posttraumatic stress disorder. All of the subjects were outpatients at 26 VA medical centers.
Combined, the mean age of the study participants was 53.6 years, plus or minus 11 years, and 86.2% were male. Whites made up 57.4% of the sample, followed by blacks (37.0%) and other (5.6%). A total of 27% had no comorbid psychiatric conditions.
The study authors found documented suicidal ideation or suicidal behavior in 69.9% of veterans with schizophrenia and 82.3% of those with bipolar disorder; the percentages who reported making actual suicide attempts was 46.1% schizophrenia and 54.5% bipolar disorder.
The risk of suicidal ideation was lower in schizophrenia vs. bipolar disorder (odds ratio, 0.82; 95% confidence interval, 0.71-0.95), as was suicidal behavior (OR, 0.81; 95% CI, 0.71-0.93).
Dr. Harvey said this is not surprising. “The combination of a history of euphoric mood and significant depression [characteristic of bipolar disorder] is very challenging.”
Other factors lowered risk: College education vs. high school or less (OR, 0.82; 95% CI, 0.67-1.00 for ideation; OR, 0.70; 95% CI, 0.58-0.84 for behavior). In addition, lower risk was found among black vs. white patients (OR, 0.72; 95% CI, 0.63-0.84 for ideation; OR, 0.82; 95% CI, 0.72-0.93, for behavior).
These factors boosted risk: multiple psychiatric comorbidities vs. none (OR, 2.61; 95% CI, 2.22-3.07 for ideation; OR, 3.82; 95% CI, 3.30-4.41, for behavior), and those with a history of being ever vs. never married (OR, 1.18; 95% CI, 1.02-1.37 for ideation; OR, 1.36; 95% CI, 1.19-1.55, for behavior). Most of those who had been married later were divorced.
“These findings underscore the need for continuous monitoring for suicidality in veteran populations, regardless of age or psychiatric diagnosis, and especially with multiple psychiatric comorbidities,” the authors wrote.
The study was funded by the Department of Veterans Affairs Cooperative Study Program. Dr. Harvey reported no relevant disclosures.
SAN DIEGO – A new study reports that about half of assessed U.S. veterans with schizophrenia or bipolar I disorder have tried to kill themselves. Nearly 70% of those with schizophrenia had documented suicidal behavior or ideation, as did more than 82% of those with bipolar I disorder.
“The VA struggles to predict suicidal ideation and behavior,” said study lead author Philip D. Harvey, PhD, of the Carter VA Medical Center in Miami, in an interview. “These data suggest that having one of these diagnoses is a major risk factor. Regular assessment makes considerable sense.”
Dr. Harvey released the study findings in a poster at the annual meeting of the American Psychiatric Association.
For the study, Dr. Harvey and his colleagues examined findings from a VA research project into the genetics behind functional disability in schizophrenia and bipolar illness.
“We know that suicide risk is higher in veterans than in the general population. We also know that the current focus is on returning veterans who were deployed in combat operations,” said Dr. Harvey, who also is affiliated with the University of Miami. “We wanted to evaluate the risk for suicidal ideation and behavior in the segment of the veteran population who have recently or ever been exposed to military trauma.”
The project assessed VA patients with schizophrenia (N = 3,941) or bipolar I disorder (N = 5,414) through in-person evaluations regarding issues like cognitive and functional status, and history of posttraumatic stress disorder. All of the subjects were outpatients at 26 VA medical centers.
Combined, the mean age of the study participants was 53.6 years, plus or minus 11 years, and 86.2% were male. Whites made up 57.4% of the sample, followed by blacks (37.0%) and other (5.6%). A total of 27% had no comorbid psychiatric conditions.
The study authors found documented suicidal ideation or suicidal behavior in 69.9% of veterans with schizophrenia and 82.3% of those with bipolar disorder; the percentages who reported making actual suicide attempts was 46.1% schizophrenia and 54.5% bipolar disorder.
The risk of suicidal ideation was lower in schizophrenia vs. bipolar disorder (odds ratio, 0.82; 95% confidence interval, 0.71-0.95), as was suicidal behavior (OR, 0.81; 95% CI, 0.71-0.93).
Dr. Harvey said this is not surprising. “The combination of a history of euphoric mood and significant depression [characteristic of bipolar disorder] is very challenging.”
Other factors lowered risk: College education vs. high school or less (OR, 0.82; 95% CI, 0.67-1.00 for ideation; OR, 0.70; 95% CI, 0.58-0.84 for behavior). In addition, lower risk was found among black vs. white patients (OR, 0.72; 95% CI, 0.63-0.84 for ideation; OR, 0.82; 95% CI, 0.72-0.93, for behavior).
These factors boosted risk: multiple psychiatric comorbidities vs. none (OR, 2.61; 95% CI, 2.22-3.07 for ideation; OR, 3.82; 95% CI, 3.30-4.41, for behavior), and those with a history of being ever vs. never married (OR, 1.18; 95% CI, 1.02-1.37 for ideation; OR, 1.36; 95% CI, 1.19-1.55, for behavior). Most of those who had been married later were divorced.
“These findings underscore the need for continuous monitoring for suicidality in veteran populations, regardless of age or psychiatric diagnosis, and especially with multiple psychiatric comorbidities,” the authors wrote.
The study was funded by the Department of Veterans Affairs Cooperative Study Program. Dr. Harvey reported no relevant disclosures.
SAN DIEGO – A new study reports that about half of assessed U.S. veterans with schizophrenia or bipolar I disorder have tried to kill themselves. Nearly 70% of those with schizophrenia had documented suicidal behavior or ideation, as did more than 82% of those with bipolar I disorder.
“The VA struggles to predict suicidal ideation and behavior,” said study lead author Philip D. Harvey, PhD, of the Carter VA Medical Center in Miami, in an interview. “These data suggest that having one of these diagnoses is a major risk factor. Regular assessment makes considerable sense.”
Dr. Harvey released the study findings in a poster at the annual meeting of the American Psychiatric Association.
For the study, Dr. Harvey and his colleagues examined findings from a VA research project into the genetics behind functional disability in schizophrenia and bipolar illness.
“We know that suicide risk is higher in veterans than in the general population. We also know that the current focus is on returning veterans who were deployed in combat operations,” said Dr. Harvey, who also is affiliated with the University of Miami. “We wanted to evaluate the risk for suicidal ideation and behavior in the segment of the veteran population who have recently or ever been exposed to military trauma.”
The project assessed VA patients with schizophrenia (N = 3,941) or bipolar I disorder (N = 5,414) through in-person evaluations regarding issues like cognitive and functional status, and history of posttraumatic stress disorder. All of the subjects were outpatients at 26 VA medical centers.
Combined, the mean age of the study participants was 53.6 years, plus or minus 11 years, and 86.2% were male. Whites made up 57.4% of the sample, followed by blacks (37.0%) and other (5.6%). A total of 27% had no comorbid psychiatric conditions.
The study authors found documented suicidal ideation or suicidal behavior in 69.9% of veterans with schizophrenia and 82.3% of those with bipolar disorder; the percentages who reported making actual suicide attempts was 46.1% schizophrenia and 54.5% bipolar disorder.
The risk of suicidal ideation was lower in schizophrenia vs. bipolar disorder (odds ratio, 0.82; 95% confidence interval, 0.71-0.95), as was suicidal behavior (OR, 0.81; 95% CI, 0.71-0.93).
Dr. Harvey said this is not surprising. “The combination of a history of euphoric mood and significant depression [characteristic of bipolar disorder] is very challenging.”
Other factors lowered risk: College education vs. high school or less (OR, 0.82; 95% CI, 0.67-1.00 for ideation; OR, 0.70; 95% CI, 0.58-0.84 for behavior). In addition, lower risk was found among black vs. white patients (OR, 0.72; 95% CI, 0.63-0.84 for ideation; OR, 0.82; 95% CI, 0.72-0.93, for behavior).
These factors boosted risk: multiple psychiatric comorbidities vs. none (OR, 2.61; 95% CI, 2.22-3.07 for ideation; OR, 3.82; 95% CI, 3.30-4.41, for behavior), and those with a history of being ever vs. never married (OR, 1.18; 95% CI, 1.02-1.37 for ideation; OR, 1.36; 95% CI, 1.19-1.55, for behavior). Most of those who had been married later were divorced.
“These findings underscore the need for continuous monitoring for suicidality in veteran populations, regardless of age or psychiatric diagnosis, and especially with multiple psychiatric comorbidities,” the authors wrote.
The study was funded by the Department of Veterans Affairs Cooperative Study Program. Dr. Harvey reported no relevant disclosures.
AT APA
Key clinical point: Roughly half of U.S. veterans with schizophrenia or bipolar I disorder have tried to kill themselves, and most of these veterans have histories of suicidal ideation or behavior.
Major finding: Suicide attempts are reported in 46.1% of patients with schizophrenia and 54.5% of those with bipolar I disorder. Documented suicidal ideation or behavior is reported in 69.9% of veterans with schizophrenia and 82.3% of those with bipolar disorder.
Data source: A genomic study with in-person assessments of VA patients with schizophrenia (N = 3,941) or bipolar disorder (N = 5,414). The mean age was 53.6 years, plus or minus 11 years; 86.2% were male, and 57.4% were white.
Disclosures: The study was funded by the Department of Veterans Affairs Cooperative Study Program.
Algorithm aims to tackle clozapine resistance
SAN DIEGO – The atypical antipsychotic drug clozapine is the standard of care for patients with treatment-resistant schizophrenia, but about half do not see an adequate response.
At the annual meeting of the American Psychiatric Association, Randall F. White, MD, presented an algorithm for clozapine-resistant patients intended to simplify and clarify a path forward. He also presented outcome data from a cohort of patients managed using this approach.
The algorithm recommends electroconvulsive therapy if there is inadequate response to clozapine alone or with fluvoxamine, which sometimes is used to boost clozapine serum level, especially in patients who are heavy smokers. If ECT fails to reduce symptoms or the patient refuses it, topiramate, aripiprazole, or sulpiride may be added to clozapine treatment, said Dr. White of the University of British Columbia, Vancouver.
And finally, if psychosis persists, certain patients should be offered cognitive-behavioral therapy with a psychologist trained in helping people with psychosis, Dr. White and his colleagues advise.
Dr. White said in an interview that the idea for a systematic approach to clozapine resistance came from clinical experience of the British Columbia Psychosis Program, which specializes in patients with severe schizophrenia and treatment resistance.
“About half of our patients come to us already on clozapine and aren’t getting better, so we needed to figure out a coherent approach to help them,” he said, noting that there is no current standard of care and that many “come to us already on four or five medications, and it can seem a bit random.”
When these patients are admitted, “we try to simplify their treatment and figure out what’s going on, and then offer ECT if appropriate,” he said.
Dr. White presented data from a cohort of patients assessed at the program between 2012 and 2017, of which 114 were taking clozapine at admission and had a diagnosis of schizophrenia or schizoaffective disorder.
To be considered clozapine-resistant, patients had to be taking 500 mg or more for at least 60 days, yet have persistent positive symptoms and moderate to severe impairment. Dr. White and his colleagues identified 20 patients with clozapine resistance. Of these, eight were offered ECT, and three accepted. At the time of discharge, 16 patients remained on clozapine with or without fluvoxamine. Four patients were treated with the recommended adjunctive agents aripiprazole or sulpiride and five with other agents.
Dr. White said the three agents recommended in the algorithm were determined by literature reviews, including meta-analyses of randomized trials. Several commonly used adjunctive agents to clozapine, including risperidone, were ruled out, for lack of evidence in this patient group.
Sulpiride, one of the drugs recommended in the algorithm, is not marketed in North America, and in Canada is accessible only by special arrangement. The evidence for aripiprazole, meanwhile, “is not stupendous,” Dr. White said, “but there’s a signal.”
The topiramate recommendation is based on results from a 2016 meta-analysis of randomized controlled trials. “Topiramate has a possible advantage of ameliorating metabolic problems,” Dr. White said, and the meta-analysis showed a significant effect size in improving positive and negative symptoms. However, he noted, on rare occasions, it has been seen to exacerbate psychosis.
Dr. White said few of the treatment-resistant patients seen in his program have had a course of ECT despite evidence of benefit. “Instead of ECT, they usually are put on multiple medications,” he said. “Admittedly, getting some of these patients to accept ECT isn’t easy.”
Because the program is designed to keep patients for 6 or more months as needed, “we have the luxury of time,” Dr. White said, to allow for the discontinuation of extraneous medicines and for an ECT trial if indicated.
“I know that in other hospitals, and other health care settings, they don’t have that – they have to figure out what to do quickly. And ECT is not the quickest treatment.”
Offering cognitive-behavioral therapy to people with psychosis is possible, he stressed, and supported by evidence from at least one study. “In this population, it’s challenging,” he acknowledged. “I don’t think I’d do it concurrently with ECT but as an alternative to or after ECT.”
Dr. White disclosed no conflicts of interest related to his research.
SAN DIEGO – The atypical antipsychotic drug clozapine is the standard of care for patients with treatment-resistant schizophrenia, but about half do not see an adequate response.
At the annual meeting of the American Psychiatric Association, Randall F. White, MD, presented an algorithm for clozapine-resistant patients intended to simplify and clarify a path forward. He also presented outcome data from a cohort of patients managed using this approach.
The algorithm recommends electroconvulsive therapy if there is inadequate response to clozapine alone or with fluvoxamine, which sometimes is used to boost clozapine serum level, especially in patients who are heavy smokers. If ECT fails to reduce symptoms or the patient refuses it, topiramate, aripiprazole, or sulpiride may be added to clozapine treatment, said Dr. White of the University of British Columbia, Vancouver.
And finally, if psychosis persists, certain patients should be offered cognitive-behavioral therapy with a psychologist trained in helping people with psychosis, Dr. White and his colleagues advise.
Dr. White said in an interview that the idea for a systematic approach to clozapine resistance came from clinical experience of the British Columbia Psychosis Program, which specializes in patients with severe schizophrenia and treatment resistance.
“About half of our patients come to us already on clozapine and aren’t getting better, so we needed to figure out a coherent approach to help them,” he said, noting that there is no current standard of care and that many “come to us already on four or five medications, and it can seem a bit random.”
When these patients are admitted, “we try to simplify their treatment and figure out what’s going on, and then offer ECT if appropriate,” he said.
Dr. White presented data from a cohort of patients assessed at the program between 2012 and 2017, of which 114 were taking clozapine at admission and had a diagnosis of schizophrenia or schizoaffective disorder.
To be considered clozapine-resistant, patients had to be taking 500 mg or more for at least 60 days, yet have persistent positive symptoms and moderate to severe impairment. Dr. White and his colleagues identified 20 patients with clozapine resistance. Of these, eight were offered ECT, and three accepted. At the time of discharge, 16 patients remained on clozapine with or without fluvoxamine. Four patients were treated with the recommended adjunctive agents aripiprazole or sulpiride and five with other agents.
Dr. White said the three agents recommended in the algorithm were determined by literature reviews, including meta-analyses of randomized trials. Several commonly used adjunctive agents to clozapine, including risperidone, were ruled out, for lack of evidence in this patient group.
Sulpiride, one of the drugs recommended in the algorithm, is not marketed in North America, and in Canada is accessible only by special arrangement. The evidence for aripiprazole, meanwhile, “is not stupendous,” Dr. White said, “but there’s a signal.”
The topiramate recommendation is based on results from a 2016 meta-analysis of randomized controlled trials. “Topiramate has a possible advantage of ameliorating metabolic problems,” Dr. White said, and the meta-analysis showed a significant effect size in improving positive and negative symptoms. However, he noted, on rare occasions, it has been seen to exacerbate psychosis.
Dr. White said few of the treatment-resistant patients seen in his program have had a course of ECT despite evidence of benefit. “Instead of ECT, they usually are put on multiple medications,” he said. “Admittedly, getting some of these patients to accept ECT isn’t easy.”
Because the program is designed to keep patients for 6 or more months as needed, “we have the luxury of time,” Dr. White said, to allow for the discontinuation of extraneous medicines and for an ECT trial if indicated.
“I know that in other hospitals, and other health care settings, they don’t have that – they have to figure out what to do quickly. And ECT is not the quickest treatment.”
Offering cognitive-behavioral therapy to people with psychosis is possible, he stressed, and supported by evidence from at least one study. “In this population, it’s challenging,” he acknowledged. “I don’t think I’d do it concurrently with ECT but as an alternative to or after ECT.”
Dr. White disclosed no conflicts of interest related to his research.
SAN DIEGO – The atypical antipsychotic drug clozapine is the standard of care for patients with treatment-resistant schizophrenia, but about half do not see an adequate response.
At the annual meeting of the American Psychiatric Association, Randall F. White, MD, presented an algorithm for clozapine-resistant patients intended to simplify and clarify a path forward. He also presented outcome data from a cohort of patients managed using this approach.
The algorithm recommends electroconvulsive therapy if there is inadequate response to clozapine alone or with fluvoxamine, which sometimes is used to boost clozapine serum level, especially in patients who are heavy smokers. If ECT fails to reduce symptoms or the patient refuses it, topiramate, aripiprazole, or sulpiride may be added to clozapine treatment, said Dr. White of the University of British Columbia, Vancouver.
And finally, if psychosis persists, certain patients should be offered cognitive-behavioral therapy with a psychologist trained in helping people with psychosis, Dr. White and his colleagues advise.
Dr. White said in an interview that the idea for a systematic approach to clozapine resistance came from clinical experience of the British Columbia Psychosis Program, which specializes in patients with severe schizophrenia and treatment resistance.
“About half of our patients come to us already on clozapine and aren’t getting better, so we needed to figure out a coherent approach to help them,” he said, noting that there is no current standard of care and that many “come to us already on four or five medications, and it can seem a bit random.”
When these patients are admitted, “we try to simplify their treatment and figure out what’s going on, and then offer ECT if appropriate,” he said.
Dr. White presented data from a cohort of patients assessed at the program between 2012 and 2017, of which 114 were taking clozapine at admission and had a diagnosis of schizophrenia or schizoaffective disorder.
To be considered clozapine-resistant, patients had to be taking 500 mg or more for at least 60 days, yet have persistent positive symptoms and moderate to severe impairment. Dr. White and his colleagues identified 20 patients with clozapine resistance. Of these, eight were offered ECT, and three accepted. At the time of discharge, 16 patients remained on clozapine with or without fluvoxamine. Four patients were treated with the recommended adjunctive agents aripiprazole or sulpiride and five with other agents.
Dr. White said the three agents recommended in the algorithm were determined by literature reviews, including meta-analyses of randomized trials. Several commonly used adjunctive agents to clozapine, including risperidone, were ruled out, for lack of evidence in this patient group.
Sulpiride, one of the drugs recommended in the algorithm, is not marketed in North America, and in Canada is accessible only by special arrangement. The evidence for aripiprazole, meanwhile, “is not stupendous,” Dr. White said, “but there’s a signal.”
The topiramate recommendation is based on results from a 2016 meta-analysis of randomized controlled trials. “Topiramate has a possible advantage of ameliorating metabolic problems,” Dr. White said, and the meta-analysis showed a significant effect size in improving positive and negative symptoms. However, he noted, on rare occasions, it has been seen to exacerbate psychosis.
Dr. White said few of the treatment-resistant patients seen in his program have had a course of ECT despite evidence of benefit. “Instead of ECT, they usually are put on multiple medications,” he said. “Admittedly, getting some of these patients to accept ECT isn’t easy.”
Because the program is designed to keep patients for 6 or more months as needed, “we have the luxury of time,” Dr. White said, to allow for the discontinuation of extraneous medicines and for an ECT trial if indicated.
“I know that in other hospitals, and other health care settings, they don’t have that – they have to figure out what to do quickly. And ECT is not the quickest treatment.”
Offering cognitive-behavioral therapy to people with psychosis is possible, he stressed, and supported by evidence from at least one study. “In this population, it’s challenging,” he acknowledged. “I don’t think I’d do it concurrently with ECT but as an alternative to or after ECT.”
Dr. White disclosed no conflicts of interest related to his research.
EXPERT ANALYSIS FROM APA
Should convicted sex offender get penile prosthetic implant?
SAN DIEGO – Should a man with a distant history of pedophilia be allowed to get a penile prosthetic implant to treat his erectile dysfunction? Mental health professionals at a Veterans Affairs medical center in San Diego recently faced this question and decided the risk was too great. They denied his request.
“This kind of dilemma occurs throughout all health systems, and it’s very challenging. It obviously puts the physician in a very ethically challenging situation,” said Kristin Beizai, MD, a psychiatrist and coauthor of a case report presented at the annual meeting of the American Psychiatric Association.
Yash B. Joshi, MD, PhD, and Dr. Beizai, both psychiatrists at the University of California, San Diego, and the VA San Diego Healthcare System, reported the penile prosthetic implant case in a poster at APA.
According to them, a married veteran sought treatment for erectile dysfunction (ED) from VA hospital urologists after oral treatment had failed. The elderly man, who had been imprisoned for 3 years some 25-30 years previously, sought a penile prosthetic implant – an alternative to treatments for ED when drugs have failed. Other options include self-injections and vacuum devices.
Men with the implants trigger erections by squeezing a pump in the scrotum that allows fluid to flow from a reservoir into the cylinder.
The man had been imprisoned in his 40s for 3 years because of a single incident of sexually abusing a toddler. According to the case report, his primary care doctors previously had offered him ED treatments “without acknowledging this history in their clinical-decision making process.”
A psychologist determined the man to be at low risk of committing a sexual offense again and cleared him for an implant. But his urologists requested an ethics consultation, which was provided by a team that included representatives from the fields of psychiatry, internal medicine, nursing, and social work.
“The ethics team determined that the most appropriate course of action hinged on a thorough and individualized risk-benefit assessment to determine if providing the treatment was ethically justifiable,” Dr. Beizai said in an interview.
An on-site psychologist and an outside expert evaluated the patient using a tool known as the Violence Risk Assessment Instrument–Sexual and determined the man was at moderate to severe risk of committing a sexual offense again.
“It was also discovered that the patient never completed treatment for pedophilia in the community as previously recommended,” the psychiatrists reported. “He was offered a plan for reevaluation and rehabilitation by subspecialists but declined this option.”
The man subsequently died of natural causes.
Dr. Beizai said those kinds of cases present numerous challenges. “This case involves surgery/urology, but this is an issue with primary care as well, and they likely do not have the time, resources, or protocol to address fully, particularly when legal information may be withheld and there are confidentiality issues.”
In regard to a risk-benefit analysis, she said, “a general mental health practitioner may not be comfortable completing this kind of assessment, and there may be an indication to refer to a forensic psychiatrist or psychologist. But this can be an expensive and scarce resource.”
There’s also the potential for political storms if the news gets out that a convicted sex offender received ED treatment. News reports in the mid-2000s about this kind of care persuaded several states to ban government payments for ED treatment for convicted sex offenders, and Medicaid funding was eliminated.
Two researchers who study pedophilia said in an interview that these decisions are far from simple and must take several factors into account.
Fred S. Berlin, MD, PhD, director of the Sexual Behavior Consultation Unit, and associate professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore, said a sexual offense background isn’t necessarily enough of a reason to deny ED treatment to a patient. Important factors for decision making, he said, include the nature of the previous offenses (such as whether they involved penile penetration, or the use of drugs or alcohol) and the state of an offender’s current relationship.
He added that it’s important to understand that the lack of functioning genitals isn’t a barrier to sexual abuse. “There shouldn’t be a narrow focus on the capacity of the penis to have an erection,” he said.
Treatment for ED in convicted sex offenders can be helpful in some cases, said Richard B. Krueger, MD, an associate clinical professor of psychiatry at Columbia University, New York, and medical director of the Sexual Behavior Clinic at New York State Psychiatric Institute. “The general sense is that it would be a benefit to enable an appropriate, peer-related relationship with a spouse, significant other, or adults,” Dr. Krueger said.
Red flags regarding ED treatment in sex offenders, he said, include high scores on predictive tests, a history of extreme sadism or sociopathy, and challenges regarding monitoring of the offender.
Dr. Beizai, Dr. Joshi, Dr. Krueger, and Dr. Berlin reported no relevant disclosures.
[polldaddy:9767052]
SAN DIEGO – Should a man with a distant history of pedophilia be allowed to get a penile prosthetic implant to treat his erectile dysfunction? Mental health professionals at a Veterans Affairs medical center in San Diego recently faced this question and decided the risk was too great. They denied his request.
“This kind of dilemma occurs throughout all health systems, and it’s very challenging. It obviously puts the physician in a very ethically challenging situation,” said Kristin Beizai, MD, a psychiatrist and coauthor of a case report presented at the annual meeting of the American Psychiatric Association.
Yash B. Joshi, MD, PhD, and Dr. Beizai, both psychiatrists at the University of California, San Diego, and the VA San Diego Healthcare System, reported the penile prosthetic implant case in a poster at APA.
According to them, a married veteran sought treatment for erectile dysfunction (ED) from VA hospital urologists after oral treatment had failed. The elderly man, who had been imprisoned for 3 years some 25-30 years previously, sought a penile prosthetic implant – an alternative to treatments for ED when drugs have failed. Other options include self-injections and vacuum devices.
Men with the implants trigger erections by squeezing a pump in the scrotum that allows fluid to flow from a reservoir into the cylinder.
The man had been imprisoned in his 40s for 3 years because of a single incident of sexually abusing a toddler. According to the case report, his primary care doctors previously had offered him ED treatments “without acknowledging this history in their clinical-decision making process.”
A psychologist determined the man to be at low risk of committing a sexual offense again and cleared him for an implant. But his urologists requested an ethics consultation, which was provided by a team that included representatives from the fields of psychiatry, internal medicine, nursing, and social work.
“The ethics team determined that the most appropriate course of action hinged on a thorough and individualized risk-benefit assessment to determine if providing the treatment was ethically justifiable,” Dr. Beizai said in an interview.
An on-site psychologist and an outside expert evaluated the patient using a tool known as the Violence Risk Assessment Instrument–Sexual and determined the man was at moderate to severe risk of committing a sexual offense again.
“It was also discovered that the patient never completed treatment for pedophilia in the community as previously recommended,” the psychiatrists reported. “He was offered a plan for reevaluation and rehabilitation by subspecialists but declined this option.”
The man subsequently died of natural causes.
Dr. Beizai said those kinds of cases present numerous challenges. “This case involves surgery/urology, but this is an issue with primary care as well, and they likely do not have the time, resources, or protocol to address fully, particularly when legal information may be withheld and there are confidentiality issues.”
In regard to a risk-benefit analysis, she said, “a general mental health practitioner may not be comfortable completing this kind of assessment, and there may be an indication to refer to a forensic psychiatrist or psychologist. But this can be an expensive and scarce resource.”
There’s also the potential for political storms if the news gets out that a convicted sex offender received ED treatment. News reports in the mid-2000s about this kind of care persuaded several states to ban government payments for ED treatment for convicted sex offenders, and Medicaid funding was eliminated.
Two researchers who study pedophilia said in an interview that these decisions are far from simple and must take several factors into account.
Fred S. Berlin, MD, PhD, director of the Sexual Behavior Consultation Unit, and associate professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore, said a sexual offense background isn’t necessarily enough of a reason to deny ED treatment to a patient. Important factors for decision making, he said, include the nature of the previous offenses (such as whether they involved penile penetration, or the use of drugs or alcohol) and the state of an offender’s current relationship.
He added that it’s important to understand that the lack of functioning genitals isn’t a barrier to sexual abuse. “There shouldn’t be a narrow focus on the capacity of the penis to have an erection,” he said.
Treatment for ED in convicted sex offenders can be helpful in some cases, said Richard B. Krueger, MD, an associate clinical professor of psychiatry at Columbia University, New York, and medical director of the Sexual Behavior Clinic at New York State Psychiatric Institute. “The general sense is that it would be a benefit to enable an appropriate, peer-related relationship with a spouse, significant other, or adults,” Dr. Krueger said.
Red flags regarding ED treatment in sex offenders, he said, include high scores on predictive tests, a history of extreme sadism or sociopathy, and challenges regarding monitoring of the offender.
Dr. Beizai, Dr. Joshi, Dr. Krueger, and Dr. Berlin reported no relevant disclosures.
[polldaddy:9767052]
SAN DIEGO – Should a man with a distant history of pedophilia be allowed to get a penile prosthetic implant to treat his erectile dysfunction? Mental health professionals at a Veterans Affairs medical center in San Diego recently faced this question and decided the risk was too great. They denied his request.
“This kind of dilemma occurs throughout all health systems, and it’s very challenging. It obviously puts the physician in a very ethically challenging situation,” said Kristin Beizai, MD, a psychiatrist and coauthor of a case report presented at the annual meeting of the American Psychiatric Association.
Yash B. Joshi, MD, PhD, and Dr. Beizai, both psychiatrists at the University of California, San Diego, and the VA San Diego Healthcare System, reported the penile prosthetic implant case in a poster at APA.
According to them, a married veteran sought treatment for erectile dysfunction (ED) from VA hospital urologists after oral treatment had failed. The elderly man, who had been imprisoned for 3 years some 25-30 years previously, sought a penile prosthetic implant – an alternative to treatments for ED when drugs have failed. Other options include self-injections and vacuum devices.
Men with the implants trigger erections by squeezing a pump in the scrotum that allows fluid to flow from a reservoir into the cylinder.
The man had been imprisoned in his 40s for 3 years because of a single incident of sexually abusing a toddler. According to the case report, his primary care doctors previously had offered him ED treatments “without acknowledging this history in their clinical-decision making process.”
A psychologist determined the man to be at low risk of committing a sexual offense again and cleared him for an implant. But his urologists requested an ethics consultation, which was provided by a team that included representatives from the fields of psychiatry, internal medicine, nursing, and social work.
“The ethics team determined that the most appropriate course of action hinged on a thorough and individualized risk-benefit assessment to determine if providing the treatment was ethically justifiable,” Dr. Beizai said in an interview.
An on-site psychologist and an outside expert evaluated the patient using a tool known as the Violence Risk Assessment Instrument–Sexual and determined the man was at moderate to severe risk of committing a sexual offense again.
“It was also discovered that the patient never completed treatment for pedophilia in the community as previously recommended,” the psychiatrists reported. “He was offered a plan for reevaluation and rehabilitation by subspecialists but declined this option.”
The man subsequently died of natural causes.
Dr. Beizai said those kinds of cases present numerous challenges. “This case involves surgery/urology, but this is an issue with primary care as well, and they likely do not have the time, resources, or protocol to address fully, particularly when legal information may be withheld and there are confidentiality issues.”
In regard to a risk-benefit analysis, she said, “a general mental health practitioner may not be comfortable completing this kind of assessment, and there may be an indication to refer to a forensic psychiatrist or psychologist. But this can be an expensive and scarce resource.”
There’s also the potential for political storms if the news gets out that a convicted sex offender received ED treatment. News reports in the mid-2000s about this kind of care persuaded several states to ban government payments for ED treatment for convicted sex offenders, and Medicaid funding was eliminated.
Two researchers who study pedophilia said in an interview that these decisions are far from simple and must take several factors into account.
Fred S. Berlin, MD, PhD, director of the Sexual Behavior Consultation Unit, and associate professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore, said a sexual offense background isn’t necessarily enough of a reason to deny ED treatment to a patient. Important factors for decision making, he said, include the nature of the previous offenses (such as whether they involved penile penetration, or the use of drugs or alcohol) and the state of an offender’s current relationship.
He added that it’s important to understand that the lack of functioning genitals isn’t a barrier to sexual abuse. “There shouldn’t be a narrow focus on the capacity of the penis to have an erection,” he said.
Treatment for ED in convicted sex offenders can be helpful in some cases, said Richard B. Krueger, MD, an associate clinical professor of psychiatry at Columbia University, New York, and medical director of the Sexual Behavior Clinic at New York State Psychiatric Institute. “The general sense is that it would be a benefit to enable an appropriate, peer-related relationship with a spouse, significant other, or adults,” Dr. Krueger said.
Red flags regarding ED treatment in sex offenders, he said, include high scores on predictive tests, a history of extreme sadism or sociopathy, and challenges regarding monitoring of the offender.
Dr. Beizai, Dr. Joshi, Dr. Krueger, and Dr. Berlin reported no relevant disclosures.
[polldaddy:9767052]
AT APA