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Postpartum depression: Moving toward improved screening with a new app
Over the last several years, there’s been increasing interest and ultimately a growing number of mandates across dozens of states to screen women for postpartum depression (PPD). As PPD is the most common, and often devastating, complication in modern obstetrics, screening for it is a movement that I fully support.
What’s been challenging is how to roll out screening in a widespread fashion using a standardized tool that is both easy to use and to score, and that has only a modest number of false positives (i.e., it has good specificity).
The first version of the MGHPDS app combines the Edinburgh Postpartum Depression Scale (EPDS) – the most commonly used screen for PPD – with screening tools that measure sleep disturbance, anxiety, and stress. And while the Edinburgh scale has been an enormous contribution to psychiatry, its implementation in obstetric settings and community settings using pen and pencil has been a challenge at times given the inclusion of some questions that are “reverse scored”; other problems when the EPDS has been scaled for use in large settings include rates of false positives as high as 25%.
Our app, which gives users an opportunity to let us review their scores after giving informed consent, ultimately will lead to the development of a shortened set of questions that zero in on the symptoms most commonly associated with PPD. That information will derive from a validation study looking at how well the questions on the MGHPDS correlate with major depression; we hope to launch version 2.0 in mid-2018. The second version of the app is likely to include some items from the Edinburgh scale and also selected symptoms of anxiety, sleep problems, and perceived stress. Thus, the goal of the second version will be realized: a more specific scale with targeted symptoms that correlate with the clinical diagnosis of depression.
Automatic scoring of the questionnaires leads to an app-generated result across a spectrum from “no evidence of depressive symptoms,” to a message noting concern and instructing the user to seek medical attention. There are also links to educational resources about PPD within the app.
The task of referring women with PPD for treatment and then getting them well is a huge undertaking, and one where we currently are falling short. I have been heartened across the last decade to see the focus land on the issue of PPD screening, but failing to couple screening with evidence-based treatment is an incomplete victory. So with the next version of the app, we want to include treatment tools and a way to track women over time, looking at whether they were treated and if they got well.
We want clinicians to be aware of our app and to share it with their patients. But even more importantly, we want to reach out directly to women because they will lead the way on this effort.
The stakes for unrecognized and untreated PPD are simply too great for women, children, and their families.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications.
Over the last several years, there’s been increasing interest and ultimately a growing number of mandates across dozens of states to screen women for postpartum depression (PPD). As PPD is the most common, and often devastating, complication in modern obstetrics, screening for it is a movement that I fully support.
What’s been challenging is how to roll out screening in a widespread fashion using a standardized tool that is both easy to use and to score, and that has only a modest number of false positives (i.e., it has good specificity).
The first version of the MGHPDS app combines the Edinburgh Postpartum Depression Scale (EPDS) – the most commonly used screen for PPD – with screening tools that measure sleep disturbance, anxiety, and stress. And while the Edinburgh scale has been an enormous contribution to psychiatry, its implementation in obstetric settings and community settings using pen and pencil has been a challenge at times given the inclusion of some questions that are “reverse scored”; other problems when the EPDS has been scaled for use in large settings include rates of false positives as high as 25%.
Our app, which gives users an opportunity to let us review their scores after giving informed consent, ultimately will lead to the development of a shortened set of questions that zero in on the symptoms most commonly associated with PPD. That information will derive from a validation study looking at how well the questions on the MGHPDS correlate with major depression; we hope to launch version 2.0 in mid-2018. The second version of the app is likely to include some items from the Edinburgh scale and also selected symptoms of anxiety, sleep problems, and perceived stress. Thus, the goal of the second version will be realized: a more specific scale with targeted symptoms that correlate with the clinical diagnosis of depression.
Automatic scoring of the questionnaires leads to an app-generated result across a spectrum from “no evidence of depressive symptoms,” to a message noting concern and instructing the user to seek medical attention. There are also links to educational resources about PPD within the app.
The task of referring women with PPD for treatment and then getting them well is a huge undertaking, and one where we currently are falling short. I have been heartened across the last decade to see the focus land on the issue of PPD screening, but failing to couple screening with evidence-based treatment is an incomplete victory. So with the next version of the app, we want to include treatment tools and a way to track women over time, looking at whether they were treated and if they got well.
We want clinicians to be aware of our app and to share it with their patients. But even more importantly, we want to reach out directly to women because they will lead the way on this effort.
The stakes for unrecognized and untreated PPD are simply too great for women, children, and their families.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications.
Over the last several years, there’s been increasing interest and ultimately a growing number of mandates across dozens of states to screen women for postpartum depression (PPD). As PPD is the most common, and often devastating, complication in modern obstetrics, screening for it is a movement that I fully support.
What’s been challenging is how to roll out screening in a widespread fashion using a standardized tool that is both easy to use and to score, and that has only a modest number of false positives (i.e., it has good specificity).
The first version of the MGHPDS app combines the Edinburgh Postpartum Depression Scale (EPDS) – the most commonly used screen for PPD – with screening tools that measure sleep disturbance, anxiety, and stress. And while the Edinburgh scale has been an enormous contribution to psychiatry, its implementation in obstetric settings and community settings using pen and pencil has been a challenge at times given the inclusion of some questions that are “reverse scored”; other problems when the EPDS has been scaled for use in large settings include rates of false positives as high as 25%.
Our app, which gives users an opportunity to let us review their scores after giving informed consent, ultimately will lead to the development of a shortened set of questions that zero in on the symptoms most commonly associated with PPD. That information will derive from a validation study looking at how well the questions on the MGHPDS correlate with major depression; we hope to launch version 2.0 in mid-2018. The second version of the app is likely to include some items from the Edinburgh scale and also selected symptoms of anxiety, sleep problems, and perceived stress. Thus, the goal of the second version will be realized: a more specific scale with targeted symptoms that correlate with the clinical diagnosis of depression.
Automatic scoring of the questionnaires leads to an app-generated result across a spectrum from “no evidence of depressive symptoms,” to a message noting concern and instructing the user to seek medical attention. There are also links to educational resources about PPD within the app.
The task of referring women with PPD for treatment and then getting them well is a huge undertaking, and one where we currently are falling short. I have been heartened across the last decade to see the focus land on the issue of PPD screening, but failing to couple screening with evidence-based treatment is an incomplete victory. So with the next version of the app, we want to include treatment tools and a way to track women over time, looking at whether they were treated and if they got well.
We want clinicians to be aware of our app and to share it with their patients. But even more importantly, we want to reach out directly to women because they will lead the way on this effort.
The stakes for unrecognized and untreated PPD are simply too great for women, children, and their families.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications.
Integrating behavioral health and primary care
This is the fourth in a series of articles from the National Center for Excellence in Primary Care Research (NCEPCR) in the Agency for Healthcare Research and Quality (AHRQ). This series introduces sets of tools and resources designed to help your practice.
Many patients with anxiety, depression, behavioral problems, substance abuse, and other mental and behavioral health conditions turn to their primary care providers as their first, and often only, source of mental health care. Unfortunately, this care may not be as effective as patients and primary care personnel would hope or expect it to be. Problems exist with missed or inaccurate diagnoses, referrals and coordination of care, and other failures in detection and treatment (NIMH Integrated Care Web site, accessed Oct. 1, 2017).
Through the Academy’s web portal interested clinicians, health care administrators, quality improvement specialists, and others can access a wide range of resources related to behavioral health integration. A hallmark of the site is the Integration Playbook, developed as a guide to integrating behavioral health in primary care and other ambulatory care settings. The Playbook assists the growing number of primary care practices and health systems that are beginning to design and implement integrated behavioral health services. The Playbook’s implementation framework is designed to be meaningful at any level of integration development.
One challenge in implementing primary care and behavioral health integration is connecting the community engaged in integrated health care. Often behavioral health and primary care providers operate within the same building or organization but are not be aware of each other’s presence. One goal of the Academy is to unite these disparate efforts and direct providers towards one another in an attempt to facilitate collaboration. In the same vein, the Academy aims to offer resources to patients and the community on integration, including the identification of integrated practices they can access.
In addition, in order to measure quality of care in this new approach to health care delivery, the Academy created the Atlas of Integrated Behavioral Health Care Quality Measures. Intended for practices and teams that wish to understand whether they are providing high-quality integrated behavioral health care or are preparing to implement integrated care, the Atlas aims to support the field of integrated behavioral health care measurement by 1) presenting a framework for understanding measurement of integrated care; 2) providing a list of existing measures relevant to integrated behavioral health care; and 3) organizing the measures by the framework and by user goals to facilitate selection of measures.
Links from the NCEPCR site:
Tools and Resources for Research, Quality Improvement, and Practice
https://www.ahrq.gov/ncepcr/research-qi-practice/practice-transformation-qi.html
Academy Web Portal: https://www.integrationacademy.ahrq.gov
The Integration Playbook: https://integrationacademy.ahrq.gov/playbook/about-playbook
Lexicon: https://integrationacademy.ahrq.gov/lexicon
Atlas of Integrated Behavioral Health Care Quality Measures: https://integrationacademy.ahrq.gov/resources/ibhc-measures-atlas
These and other tools can be found at the NCEPCR Web site: https://www.ahrq.gov/ncepcr.
Dr. Genevro is a health scientist at AHRQ. Dr. Ganiats is director, National Center for Excellence in Primary Care Research, AHRQ.
This is the fourth in a series of articles from the National Center for Excellence in Primary Care Research (NCEPCR) in the Agency for Healthcare Research and Quality (AHRQ). This series introduces sets of tools and resources designed to help your practice.
Many patients with anxiety, depression, behavioral problems, substance abuse, and other mental and behavioral health conditions turn to their primary care providers as their first, and often only, source of mental health care. Unfortunately, this care may not be as effective as patients and primary care personnel would hope or expect it to be. Problems exist with missed or inaccurate diagnoses, referrals and coordination of care, and other failures in detection and treatment (NIMH Integrated Care Web site, accessed Oct. 1, 2017).
Through the Academy’s web portal interested clinicians, health care administrators, quality improvement specialists, and others can access a wide range of resources related to behavioral health integration. A hallmark of the site is the Integration Playbook, developed as a guide to integrating behavioral health in primary care and other ambulatory care settings. The Playbook assists the growing number of primary care practices and health systems that are beginning to design and implement integrated behavioral health services. The Playbook’s implementation framework is designed to be meaningful at any level of integration development.
One challenge in implementing primary care and behavioral health integration is connecting the community engaged in integrated health care. Often behavioral health and primary care providers operate within the same building or organization but are not be aware of each other’s presence. One goal of the Academy is to unite these disparate efforts and direct providers towards one another in an attempt to facilitate collaboration. In the same vein, the Academy aims to offer resources to patients and the community on integration, including the identification of integrated practices they can access.
In addition, in order to measure quality of care in this new approach to health care delivery, the Academy created the Atlas of Integrated Behavioral Health Care Quality Measures. Intended for practices and teams that wish to understand whether they are providing high-quality integrated behavioral health care or are preparing to implement integrated care, the Atlas aims to support the field of integrated behavioral health care measurement by 1) presenting a framework for understanding measurement of integrated care; 2) providing a list of existing measures relevant to integrated behavioral health care; and 3) organizing the measures by the framework and by user goals to facilitate selection of measures.
Links from the NCEPCR site:
Tools and Resources for Research, Quality Improvement, and Practice
https://www.ahrq.gov/ncepcr/research-qi-practice/practice-transformation-qi.html
Academy Web Portal: https://www.integrationacademy.ahrq.gov
The Integration Playbook: https://integrationacademy.ahrq.gov/playbook/about-playbook
Lexicon: https://integrationacademy.ahrq.gov/lexicon
Atlas of Integrated Behavioral Health Care Quality Measures: https://integrationacademy.ahrq.gov/resources/ibhc-measures-atlas
These and other tools can be found at the NCEPCR Web site: https://www.ahrq.gov/ncepcr.
Dr. Genevro is a health scientist at AHRQ. Dr. Ganiats is director, National Center for Excellence in Primary Care Research, AHRQ.
This is the fourth in a series of articles from the National Center for Excellence in Primary Care Research (NCEPCR) in the Agency for Healthcare Research and Quality (AHRQ). This series introduces sets of tools and resources designed to help your practice.
Many patients with anxiety, depression, behavioral problems, substance abuse, and other mental and behavioral health conditions turn to their primary care providers as their first, and often only, source of mental health care. Unfortunately, this care may not be as effective as patients and primary care personnel would hope or expect it to be. Problems exist with missed or inaccurate diagnoses, referrals and coordination of care, and other failures in detection and treatment (NIMH Integrated Care Web site, accessed Oct. 1, 2017).
Through the Academy’s web portal interested clinicians, health care administrators, quality improvement specialists, and others can access a wide range of resources related to behavioral health integration. A hallmark of the site is the Integration Playbook, developed as a guide to integrating behavioral health in primary care and other ambulatory care settings. The Playbook assists the growing number of primary care practices and health systems that are beginning to design and implement integrated behavioral health services. The Playbook’s implementation framework is designed to be meaningful at any level of integration development.
One challenge in implementing primary care and behavioral health integration is connecting the community engaged in integrated health care. Often behavioral health and primary care providers operate within the same building or organization but are not be aware of each other’s presence. One goal of the Academy is to unite these disparate efforts and direct providers towards one another in an attempt to facilitate collaboration. In the same vein, the Academy aims to offer resources to patients and the community on integration, including the identification of integrated practices they can access.
In addition, in order to measure quality of care in this new approach to health care delivery, the Academy created the Atlas of Integrated Behavioral Health Care Quality Measures. Intended for practices and teams that wish to understand whether they are providing high-quality integrated behavioral health care or are preparing to implement integrated care, the Atlas aims to support the field of integrated behavioral health care measurement by 1) presenting a framework for understanding measurement of integrated care; 2) providing a list of existing measures relevant to integrated behavioral health care; and 3) organizing the measures by the framework and by user goals to facilitate selection of measures.
Links from the NCEPCR site:
Tools and Resources for Research, Quality Improvement, and Practice
https://www.ahrq.gov/ncepcr/research-qi-practice/practice-transformation-qi.html
Academy Web Portal: https://www.integrationacademy.ahrq.gov
The Integration Playbook: https://integrationacademy.ahrq.gov/playbook/about-playbook
Lexicon: https://integrationacademy.ahrq.gov/lexicon
Atlas of Integrated Behavioral Health Care Quality Measures: https://integrationacademy.ahrq.gov/resources/ibhc-measures-atlas
These and other tools can be found at the NCEPCR Web site: https://www.ahrq.gov/ncepcr.
Dr. Genevro is a health scientist at AHRQ. Dr. Ganiats is director, National Center for Excellence in Primary Care Research, AHRQ.
ADHD and the role of wellness
ADHD is a very common disorder with several medication treatment options. There also are wellness and parenting strategies that can address aspects of the challenges of ADHD that are not perfectly covered by medication, such as excess symptoms, times of day that are not covered, or oppositional behavior that often develops secondarily.
Case summary
James is a 6-year-old boy who has been an active, high-energy child since preschool. He has had difficulty with wiggling around in kindergarten and preschool, talking excessively, and being unable to follow directions and pay attention. He is impulsive, disruptive, and frequently doesn’t listen to what his parents tell him to do. Parents and teachers rank him in the clinical range for hyperactivity, impulsivity, and attention problems on standardized rating scales.
Discussion
When we first discuss a new diagnosis with a family, we have the opportunity to shape the family’s expectations about that diagnosis and how it should be addressed. When I discuss ADHD with a new family, I want them to understand the symptoms of inattention, hyperactivity, and impulsiveness, and that these symptoms are not the child’s fault, but rather related to the way his brain is connected. At the same time, I also emphasize that these connections are not entirely fixed, that they mature over time, and that they are affected by experiences in life. In particular, I stress that positive experiences and wellness activities can influence the brain in a positive way. While, of course, I discuss the range of medications that can address these issues, I also deal with wellness in the treatment plan.
Exercise
Studies in humans and animals have provided background evidence that exercise increases the release of neurotransmitters such as dopamine and norepinephrine that are important in the pathophysiology of ADHD. Cerillo-Urbina et al. did a meta-analysis in 2015 of randomized controlled trials and found medium to large effect sizes for a variety of physical activity programs with respect to attention, hyperactivity, and impulsivity, although the study quality was generally low.1 Clearly we need additional more rigorous studies, but given the positive direction of outcomes, the lack of side effects, and the many other positive effects of exercise, it does not seem too soon to add exercise as a prescription for our patients with ADHD. I review this evidence with families, ask them about physical activity they like, and ask if they are willing to work toward an hour of exercise a day.
Sleep
Many children with ADHD have problems with sleep even before they start on stimulant medications, which can further affect sleep. Addressing sleep early on can improve ADHD symptoms, as well as help parents change or avoid patterns like having children fall asleep to the sound of a television. Brief sleep hygiene and cognitive-behavioral therapy interventions over three visits were demonstrated in a randomized controlled trial by Hisock et al. to improve ADHD symptoms and behavioral function.2 These psychosocial interventions clearly are the first line in addressing sleep problems in ADHD, and can benefit even sleep problems connected to medication.
Parent training
Treatment plan
1. Have the child exercise 1 hour every day. Have fun!
2. Establish a nightly bedtime routine, with a bath at 7:30 p.m., brushing of teeth, a story, and lights out at 8 with no TV in the room.
3. Check out the CHADD website for Parent to Parent.
4. Start a trial of stimulant medication.
5. Return in 2 weeks to monitor these interventions, adjust goals, and adjust medications.
When to refer
Many parents will be able to put such a plan in motion with your support and that of other parents. If they are struggling, therapists, psychologists, and psychiatrists trained in motivational and behavioral methods can provide more individualized parent training. Also consider whether the parents themselves may have ADHD and could use referral and treatment.
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures.
References
1. Child Care Health Dev. 2015 Nov;41(6):779-88.
2. BMJ. 2015. doi: 10.1136/bmj.h68.
ADHD is a very common disorder with several medication treatment options. There also are wellness and parenting strategies that can address aspects of the challenges of ADHD that are not perfectly covered by medication, such as excess symptoms, times of day that are not covered, or oppositional behavior that often develops secondarily.
Case summary
James is a 6-year-old boy who has been an active, high-energy child since preschool. He has had difficulty with wiggling around in kindergarten and preschool, talking excessively, and being unable to follow directions and pay attention. He is impulsive, disruptive, and frequently doesn’t listen to what his parents tell him to do. Parents and teachers rank him in the clinical range for hyperactivity, impulsivity, and attention problems on standardized rating scales.
Discussion
When we first discuss a new diagnosis with a family, we have the opportunity to shape the family’s expectations about that diagnosis and how it should be addressed. When I discuss ADHD with a new family, I want them to understand the symptoms of inattention, hyperactivity, and impulsiveness, and that these symptoms are not the child’s fault, but rather related to the way his brain is connected. At the same time, I also emphasize that these connections are not entirely fixed, that they mature over time, and that they are affected by experiences in life. In particular, I stress that positive experiences and wellness activities can influence the brain in a positive way. While, of course, I discuss the range of medications that can address these issues, I also deal with wellness in the treatment plan.
Exercise
Studies in humans and animals have provided background evidence that exercise increases the release of neurotransmitters such as dopamine and norepinephrine that are important in the pathophysiology of ADHD. Cerillo-Urbina et al. did a meta-analysis in 2015 of randomized controlled trials and found medium to large effect sizes for a variety of physical activity programs with respect to attention, hyperactivity, and impulsivity, although the study quality was generally low.1 Clearly we need additional more rigorous studies, but given the positive direction of outcomes, the lack of side effects, and the many other positive effects of exercise, it does not seem too soon to add exercise as a prescription for our patients with ADHD. I review this evidence with families, ask them about physical activity they like, and ask if they are willing to work toward an hour of exercise a day.
Sleep
Many children with ADHD have problems with sleep even before they start on stimulant medications, which can further affect sleep. Addressing sleep early on can improve ADHD symptoms, as well as help parents change or avoid patterns like having children fall asleep to the sound of a television. Brief sleep hygiene and cognitive-behavioral therapy interventions over three visits were demonstrated in a randomized controlled trial by Hisock et al. to improve ADHD symptoms and behavioral function.2 These psychosocial interventions clearly are the first line in addressing sleep problems in ADHD, and can benefit even sleep problems connected to medication.
Parent training
Treatment plan
1. Have the child exercise 1 hour every day. Have fun!
2. Establish a nightly bedtime routine, with a bath at 7:30 p.m., brushing of teeth, a story, and lights out at 8 with no TV in the room.
3. Check out the CHADD website for Parent to Parent.
4. Start a trial of stimulant medication.
5. Return in 2 weeks to monitor these interventions, adjust goals, and adjust medications.
When to refer
Many parents will be able to put such a plan in motion with your support and that of other parents. If they are struggling, therapists, psychologists, and psychiatrists trained in motivational and behavioral methods can provide more individualized parent training. Also consider whether the parents themselves may have ADHD and could use referral and treatment.
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures.
References
1. Child Care Health Dev. 2015 Nov;41(6):779-88.
2. BMJ. 2015. doi: 10.1136/bmj.h68.
ADHD is a very common disorder with several medication treatment options. There also are wellness and parenting strategies that can address aspects of the challenges of ADHD that are not perfectly covered by medication, such as excess symptoms, times of day that are not covered, or oppositional behavior that often develops secondarily.
Case summary
James is a 6-year-old boy who has been an active, high-energy child since preschool. He has had difficulty with wiggling around in kindergarten and preschool, talking excessively, and being unable to follow directions and pay attention. He is impulsive, disruptive, and frequently doesn’t listen to what his parents tell him to do. Parents and teachers rank him in the clinical range for hyperactivity, impulsivity, and attention problems on standardized rating scales.
Discussion
When we first discuss a new diagnosis with a family, we have the opportunity to shape the family’s expectations about that diagnosis and how it should be addressed. When I discuss ADHD with a new family, I want them to understand the symptoms of inattention, hyperactivity, and impulsiveness, and that these symptoms are not the child’s fault, but rather related to the way his brain is connected. At the same time, I also emphasize that these connections are not entirely fixed, that they mature over time, and that they are affected by experiences in life. In particular, I stress that positive experiences and wellness activities can influence the brain in a positive way. While, of course, I discuss the range of medications that can address these issues, I also deal with wellness in the treatment plan.
Exercise
Studies in humans and animals have provided background evidence that exercise increases the release of neurotransmitters such as dopamine and norepinephrine that are important in the pathophysiology of ADHD. Cerillo-Urbina et al. did a meta-analysis in 2015 of randomized controlled trials and found medium to large effect sizes for a variety of physical activity programs with respect to attention, hyperactivity, and impulsivity, although the study quality was generally low.1 Clearly we need additional more rigorous studies, but given the positive direction of outcomes, the lack of side effects, and the many other positive effects of exercise, it does not seem too soon to add exercise as a prescription for our patients with ADHD. I review this evidence with families, ask them about physical activity they like, and ask if they are willing to work toward an hour of exercise a day.
Sleep
Many children with ADHD have problems with sleep even before they start on stimulant medications, which can further affect sleep. Addressing sleep early on can improve ADHD symptoms, as well as help parents change or avoid patterns like having children fall asleep to the sound of a television. Brief sleep hygiene and cognitive-behavioral therapy interventions over three visits were demonstrated in a randomized controlled trial by Hisock et al. to improve ADHD symptoms and behavioral function.2 These psychosocial interventions clearly are the first line in addressing sleep problems in ADHD, and can benefit even sleep problems connected to medication.
Parent training
Treatment plan
1. Have the child exercise 1 hour every day. Have fun!
2. Establish a nightly bedtime routine, with a bath at 7:30 p.m., brushing of teeth, a story, and lights out at 8 with no TV in the room.
3. Check out the CHADD website for Parent to Parent.
4. Start a trial of stimulant medication.
5. Return in 2 weeks to monitor these interventions, adjust goals, and adjust medications.
When to refer
Many parents will be able to put such a plan in motion with your support and that of other parents. If they are struggling, therapists, psychologists, and psychiatrists trained in motivational and behavioral methods can provide more individualized parent training. Also consider whether the parents themselves may have ADHD and could use referral and treatment.
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures.
References
1. Child Care Health Dev. 2015 Nov;41(6):779-88.
2. BMJ. 2015. doi: 10.1136/bmj.h68.
Ending hazing as a rite of manhood on college campuses
Is hazing a necessary rite of passage in Greek life, or a terrible tradition that needs to end once and for all?
There can be no justification for hazing, especially after the recent tragic deaths of fraternity pledges at Florida State University, Texas State University, and Louisiana State University. The horror of hazing has been brought home by the refiling of charges against several Penn State fraternity members in the torturous death last February of Timothy Piazza, which was recorded on videotape. In response to recent deaths and injuries, some colleges have suspended Greek life activities on campus. Unfortunately, hazing deaths are not new to college campuses but have a been a problem for several years, with 40 deaths in the last decade. The majority of these deaths involved the forced consumption of large amounts of alcohol, but some have involved beatings and other forms of abuse.
What exactly is hazing? According to the organization StopHazing (stophazing.org), it is “any activity expected of someone joining or participating in a group that humiliates, degrades, abuses, or endangers them regardless of a person’s willingness to participate.” Activities may involve alcohol consumption, humiliation, sleep deprivation, physical abuse, and sexual abuse. Hazing is not just a problem of fraternities; half of college students joining clubs, teams, and other organizations experience hazing. In fact, half of young adults have been hazed by the time they graduate from high school.
Given its inherent dangers, we have to wonder, why does hazing continue? The National Public Radio show 1A offered one answer to this troubling question on its Nov. 15 show, “How to Stop Hazing.” Two panel members, a filmmaker and a professor, discussed their own hazing experiences in college fraternities that included being forced to drink too much alcohol, eating noxious products, and being subjected to violence. One of the panel members talked about hazing other people. Both men admitted that the hazing process made them feel closer to their fraternity brothers: They formed lifelong bonds and also became stronger in facing adversity. In many ways, hazing was a masculine rite of passage. Neither panel member condoned the behaviors they were subjected to or participated in, and in fact suggested that college men should find new ways to bond and have a sense of belonging.
Even though the panelists were not promoting hazing, I was struck by their almost fond recollection of these experiences. I, in contrast, have no fond memory of an incident that I would consider medical hazing. During my internship when working on an internal medicine unit, I was ordered back to work after 2 days at home with the flu, although I was still febrile and coughing up a storm. That week, I was punished with an extra night of on-call duty. This incident did not leave me embracing the camaraderie and hardiness of my medical colleagues. It left me more determined than ever to treat peers and trainees with care and compassion, and never to abuse my power.
In our own practices as psychiatrists, we can play a role in helping our young adult male patients avoid hazing experiences, which have the potential to lead to depression, anxiety, posttraumatic stress disorder, and suicidal behaviors. We can work with our male patients to develop a sense of belonging and an understanding of who they are as men, without putting their lives or others’ lives at risk. In my work as a college counseling center psychiatrist for over 2 decades, I have often addressed the issues of masculinity, friendship, and peer pressure with my male patients. For those of you who work with young adult men, particularly in the college population, here are some tips:
1. Talk with your male patients about healthy versus harmful relationships. No relationship should involve the intentional infliction of physical or emotional pain. Men will acknowledge that a man hitting a girlfriend is abusive. They need to understand that male fraternity brothers hitting each other or forcing someone to drink a large volume of alcohol is equally abusive. Encourage your patients to know their limits and set boundaries if they are asked to do something dangerous to themselves or others.
2. Role play with your patients how to say no to their peers. I did that with a patient who was drinking too much in general with his fraternity brothers. He was afraid they would reject him if he drank less. He was pleasantly surprised when they did not pressure him to drink more, but instead encouraged him to do what is healthy for him.
3. Encourage your patients to have strong social connections on campus. Well-run fraternities can provide these friendship without inflicting pain. Intramural sports, singing groups, bands, and volunteer organizations all provide great ways to connect and also have a sense of accomplishment. Social connections improve grades, physical health, and emotional health.
4. Encourage your male patients to accept who they are, without embracing one stereotype of what it means to be a man. Social media often promotes unattainable physical images, and some male patients will take supplements or even steroids to build up muscle mass. Promote a healthy lifestyle without extremes in exercise and diet. Explore with your patient what it means to be a man in the 21st century, at a time when typical gender roles are being challenged.
5. Listen for cues about your patients’ relationship with their fathers, which have a large impact on how they view masculinity. Many of the male patients I see discuss how they are trying to be more in touch with and expressive about their feelings, after watching their fathers hold in their emotions or use alcohol to numb emotional pain. Some patients have been able to model and encourage a greater openness with their fathers, while others have been met with silence. As a patient is creating his own life story, his father’s history is always in the background.
Should all fraternities be shut down to end the hazing problem? I don’t believe this is the answer. Each campus has a different fraternity culture, and fraternities on many campuses can be a positive force. I have heard young men describe how fraternities encouraged them academically, discouraged excessive drinking, and promoted ethical behavior. But given that abuses have been prevalent on certain campuses, it is incumbent upon universities to enforce safe behaviors. Fraternity brothers who hurt others should be prosecuted, not protected.
The hazing on campuses needs to stop, and we as psychiatrists should talk about this important issue with our patients and sometimes their parents. We can educate our patients about this insidious form of physical and emotional abuse; we can encourage them not to be bystanders when this happens; and we can promote a culture of respect on our campuses.
Hazing is not just a campus but a national cultural problem, as we are finding from the avalanche of news reports about sexual harassment and assault in the political and entertainment worlds. Victims are exposed to abuses and then deterred from reporting them as a condition of staying in and advancing in the professions they love. Hazing is an abuse of power that we as psychiatrists must continue to fight. We should teach our young adult men the mantra that is now being used by some fraternities, “Real men don’t haze.”
Dr. Morris is an associate professor of psychiatry and associate program director for student health psychiatry at the University of Florida, Gainesville. She is the author of The Campus Cure: A Parent’s Guide to Mental Health and Wellness for College Students, which will be published by Rowman & Littlefield of Lanham, Md., in January 2018.
Is hazing a necessary rite of passage in Greek life, or a terrible tradition that needs to end once and for all?
There can be no justification for hazing, especially after the recent tragic deaths of fraternity pledges at Florida State University, Texas State University, and Louisiana State University. The horror of hazing has been brought home by the refiling of charges against several Penn State fraternity members in the torturous death last February of Timothy Piazza, which was recorded on videotape. In response to recent deaths and injuries, some colleges have suspended Greek life activities on campus. Unfortunately, hazing deaths are not new to college campuses but have a been a problem for several years, with 40 deaths in the last decade. The majority of these deaths involved the forced consumption of large amounts of alcohol, but some have involved beatings and other forms of abuse.
What exactly is hazing? According to the organization StopHazing (stophazing.org), it is “any activity expected of someone joining or participating in a group that humiliates, degrades, abuses, or endangers them regardless of a person’s willingness to participate.” Activities may involve alcohol consumption, humiliation, sleep deprivation, physical abuse, and sexual abuse. Hazing is not just a problem of fraternities; half of college students joining clubs, teams, and other organizations experience hazing. In fact, half of young adults have been hazed by the time they graduate from high school.
Given its inherent dangers, we have to wonder, why does hazing continue? The National Public Radio show 1A offered one answer to this troubling question on its Nov. 15 show, “How to Stop Hazing.” Two panel members, a filmmaker and a professor, discussed their own hazing experiences in college fraternities that included being forced to drink too much alcohol, eating noxious products, and being subjected to violence. One of the panel members talked about hazing other people. Both men admitted that the hazing process made them feel closer to their fraternity brothers: They formed lifelong bonds and also became stronger in facing adversity. In many ways, hazing was a masculine rite of passage. Neither panel member condoned the behaviors they were subjected to or participated in, and in fact suggested that college men should find new ways to bond and have a sense of belonging.
Even though the panelists were not promoting hazing, I was struck by their almost fond recollection of these experiences. I, in contrast, have no fond memory of an incident that I would consider medical hazing. During my internship when working on an internal medicine unit, I was ordered back to work after 2 days at home with the flu, although I was still febrile and coughing up a storm. That week, I was punished with an extra night of on-call duty. This incident did not leave me embracing the camaraderie and hardiness of my medical colleagues. It left me more determined than ever to treat peers and trainees with care and compassion, and never to abuse my power.
In our own practices as psychiatrists, we can play a role in helping our young adult male patients avoid hazing experiences, which have the potential to lead to depression, anxiety, posttraumatic stress disorder, and suicidal behaviors. We can work with our male patients to develop a sense of belonging and an understanding of who they are as men, without putting their lives or others’ lives at risk. In my work as a college counseling center psychiatrist for over 2 decades, I have often addressed the issues of masculinity, friendship, and peer pressure with my male patients. For those of you who work with young adult men, particularly in the college population, here are some tips:
1. Talk with your male patients about healthy versus harmful relationships. No relationship should involve the intentional infliction of physical or emotional pain. Men will acknowledge that a man hitting a girlfriend is abusive. They need to understand that male fraternity brothers hitting each other or forcing someone to drink a large volume of alcohol is equally abusive. Encourage your patients to know their limits and set boundaries if they are asked to do something dangerous to themselves or others.
2. Role play with your patients how to say no to their peers. I did that with a patient who was drinking too much in general with his fraternity brothers. He was afraid they would reject him if he drank less. He was pleasantly surprised when they did not pressure him to drink more, but instead encouraged him to do what is healthy for him.
3. Encourage your patients to have strong social connections on campus. Well-run fraternities can provide these friendship without inflicting pain. Intramural sports, singing groups, bands, and volunteer organizations all provide great ways to connect and also have a sense of accomplishment. Social connections improve grades, physical health, and emotional health.
4. Encourage your male patients to accept who they are, without embracing one stereotype of what it means to be a man. Social media often promotes unattainable physical images, and some male patients will take supplements or even steroids to build up muscle mass. Promote a healthy lifestyle without extremes in exercise and diet. Explore with your patient what it means to be a man in the 21st century, at a time when typical gender roles are being challenged.
5. Listen for cues about your patients’ relationship with their fathers, which have a large impact on how they view masculinity. Many of the male patients I see discuss how they are trying to be more in touch with and expressive about their feelings, after watching their fathers hold in their emotions or use alcohol to numb emotional pain. Some patients have been able to model and encourage a greater openness with their fathers, while others have been met with silence. As a patient is creating his own life story, his father’s history is always in the background.
Should all fraternities be shut down to end the hazing problem? I don’t believe this is the answer. Each campus has a different fraternity culture, and fraternities on many campuses can be a positive force. I have heard young men describe how fraternities encouraged them academically, discouraged excessive drinking, and promoted ethical behavior. But given that abuses have been prevalent on certain campuses, it is incumbent upon universities to enforce safe behaviors. Fraternity brothers who hurt others should be prosecuted, not protected.
The hazing on campuses needs to stop, and we as psychiatrists should talk about this important issue with our patients and sometimes their parents. We can educate our patients about this insidious form of physical and emotional abuse; we can encourage them not to be bystanders when this happens; and we can promote a culture of respect on our campuses.
Hazing is not just a campus but a national cultural problem, as we are finding from the avalanche of news reports about sexual harassment and assault in the political and entertainment worlds. Victims are exposed to abuses and then deterred from reporting them as a condition of staying in and advancing in the professions they love. Hazing is an abuse of power that we as psychiatrists must continue to fight. We should teach our young adult men the mantra that is now being used by some fraternities, “Real men don’t haze.”
Dr. Morris is an associate professor of psychiatry and associate program director for student health psychiatry at the University of Florida, Gainesville. She is the author of The Campus Cure: A Parent’s Guide to Mental Health and Wellness for College Students, which will be published by Rowman & Littlefield of Lanham, Md., in January 2018.
Is hazing a necessary rite of passage in Greek life, or a terrible tradition that needs to end once and for all?
There can be no justification for hazing, especially after the recent tragic deaths of fraternity pledges at Florida State University, Texas State University, and Louisiana State University. The horror of hazing has been brought home by the refiling of charges against several Penn State fraternity members in the torturous death last February of Timothy Piazza, which was recorded on videotape. In response to recent deaths and injuries, some colleges have suspended Greek life activities on campus. Unfortunately, hazing deaths are not new to college campuses but have a been a problem for several years, with 40 deaths in the last decade. The majority of these deaths involved the forced consumption of large amounts of alcohol, but some have involved beatings and other forms of abuse.
What exactly is hazing? According to the organization StopHazing (stophazing.org), it is “any activity expected of someone joining or participating in a group that humiliates, degrades, abuses, or endangers them regardless of a person’s willingness to participate.” Activities may involve alcohol consumption, humiliation, sleep deprivation, physical abuse, and sexual abuse. Hazing is not just a problem of fraternities; half of college students joining clubs, teams, and other organizations experience hazing. In fact, half of young adults have been hazed by the time they graduate from high school.
Given its inherent dangers, we have to wonder, why does hazing continue? The National Public Radio show 1A offered one answer to this troubling question on its Nov. 15 show, “How to Stop Hazing.” Two panel members, a filmmaker and a professor, discussed their own hazing experiences in college fraternities that included being forced to drink too much alcohol, eating noxious products, and being subjected to violence. One of the panel members talked about hazing other people. Both men admitted that the hazing process made them feel closer to their fraternity brothers: They formed lifelong bonds and also became stronger in facing adversity. In many ways, hazing was a masculine rite of passage. Neither panel member condoned the behaviors they were subjected to or participated in, and in fact suggested that college men should find new ways to bond and have a sense of belonging.
Even though the panelists were not promoting hazing, I was struck by their almost fond recollection of these experiences. I, in contrast, have no fond memory of an incident that I would consider medical hazing. During my internship when working on an internal medicine unit, I was ordered back to work after 2 days at home with the flu, although I was still febrile and coughing up a storm. That week, I was punished with an extra night of on-call duty. This incident did not leave me embracing the camaraderie and hardiness of my medical colleagues. It left me more determined than ever to treat peers and trainees with care and compassion, and never to abuse my power.
In our own practices as psychiatrists, we can play a role in helping our young adult male patients avoid hazing experiences, which have the potential to lead to depression, anxiety, posttraumatic stress disorder, and suicidal behaviors. We can work with our male patients to develop a sense of belonging and an understanding of who they are as men, without putting their lives or others’ lives at risk. In my work as a college counseling center psychiatrist for over 2 decades, I have often addressed the issues of masculinity, friendship, and peer pressure with my male patients. For those of you who work with young adult men, particularly in the college population, here are some tips:
1. Talk with your male patients about healthy versus harmful relationships. No relationship should involve the intentional infliction of physical or emotional pain. Men will acknowledge that a man hitting a girlfriend is abusive. They need to understand that male fraternity brothers hitting each other or forcing someone to drink a large volume of alcohol is equally abusive. Encourage your patients to know their limits and set boundaries if they are asked to do something dangerous to themselves or others.
2. Role play with your patients how to say no to their peers. I did that with a patient who was drinking too much in general with his fraternity brothers. He was afraid they would reject him if he drank less. He was pleasantly surprised when they did not pressure him to drink more, but instead encouraged him to do what is healthy for him.
3. Encourage your patients to have strong social connections on campus. Well-run fraternities can provide these friendship without inflicting pain. Intramural sports, singing groups, bands, and volunteer organizations all provide great ways to connect and also have a sense of accomplishment. Social connections improve grades, physical health, and emotional health.
4. Encourage your male patients to accept who they are, without embracing one stereotype of what it means to be a man. Social media often promotes unattainable physical images, and some male patients will take supplements or even steroids to build up muscle mass. Promote a healthy lifestyle without extremes in exercise and diet. Explore with your patient what it means to be a man in the 21st century, at a time when typical gender roles are being challenged.
5. Listen for cues about your patients’ relationship with their fathers, which have a large impact on how they view masculinity. Many of the male patients I see discuss how they are trying to be more in touch with and expressive about their feelings, after watching their fathers hold in their emotions or use alcohol to numb emotional pain. Some patients have been able to model and encourage a greater openness with their fathers, while others have been met with silence. As a patient is creating his own life story, his father’s history is always in the background.
Should all fraternities be shut down to end the hazing problem? I don’t believe this is the answer. Each campus has a different fraternity culture, and fraternities on many campuses can be a positive force. I have heard young men describe how fraternities encouraged them academically, discouraged excessive drinking, and promoted ethical behavior. But given that abuses have been prevalent on certain campuses, it is incumbent upon universities to enforce safe behaviors. Fraternity brothers who hurt others should be prosecuted, not protected.
The hazing on campuses needs to stop, and we as psychiatrists should talk about this important issue with our patients and sometimes their parents. We can educate our patients about this insidious form of physical and emotional abuse; we can encourage them not to be bystanders when this happens; and we can promote a culture of respect on our campuses.
Hazing is not just a campus but a national cultural problem, as we are finding from the avalanche of news reports about sexual harassment and assault in the political and entertainment worlds. Victims are exposed to abuses and then deterred from reporting them as a condition of staying in and advancing in the professions they love. Hazing is an abuse of power that we as psychiatrists must continue to fight. We should teach our young adult men the mantra that is now being used by some fraternities, “Real men don’t haze.”
Dr. Morris is an associate professor of psychiatry and associate program director for student health psychiatry at the University of Florida, Gainesville. She is the author of The Campus Cure: A Parent’s Guide to Mental Health and Wellness for College Students, which will be published by Rowman & Littlefield of Lanham, Md., in January 2018.
A program to increase flu vaccine compliance
. It won’t hurt your bottom line either and actually will help it. A flu shot program potentially can be run by a licensed practical nurse, registered nurse, physician’s assistant, or pediatric nurse practitioner, depending on your state’s law regarding vaccine administration by other than a physician, thus freeing up the physician to see well-child and sick-call patients.
It’s easy to set up a flu shot program and run it. Start preparing in June, preceding the upcoming flu season. Designate several Saturdays and or Sundays in September, October, November, December, and January as flu shot Saturdays and/or Sundays. And if Columbus day falls on a weekday, consider adding Columbus Day to your program dates as the kids often are off from school that day (check the local school calendar).
Next, prepare a postcard to be mailed to all patients on the lists your EMR produced for you. Keep the postcard simple. Announce the program, and state the dates the flu shot program is running. Ask parents to call to make an appointment for a flu vaccine only by appointment “with the program.” In addition to mailing a postcard, announce the flu shot program by sending out automated telephone calls and emails to all three lists the EMR has produced for you. The postcard mailing is your first contact, essentially announcing the program with dates and times. An automated phone call may be used to announce a specific date for which you are “now booking.” A good option when using automated phone calls is to allow the caller to press “zero” to be connected to the office to schedule a “flu shot only” appointment! Finally, emails announcing the dates of the program simply will reinforce information about the program.
Mr. Berman has been providing practice management services to physicians and other medical providers since 1983. He is the CEO of a pediatrics practice with locations in Staten Island and Brooklyn, N.Y. He holds a faculty appointment at State University of New York, Brooklyn, as a lecturer for the department of family medicine’s residency training program. He has no disclosures to report. Email him at [email protected].
. It won’t hurt your bottom line either and actually will help it. A flu shot program potentially can be run by a licensed practical nurse, registered nurse, physician’s assistant, or pediatric nurse practitioner, depending on your state’s law regarding vaccine administration by other than a physician, thus freeing up the physician to see well-child and sick-call patients.
It’s easy to set up a flu shot program and run it. Start preparing in June, preceding the upcoming flu season. Designate several Saturdays and or Sundays in September, October, November, December, and January as flu shot Saturdays and/or Sundays. And if Columbus day falls on a weekday, consider adding Columbus Day to your program dates as the kids often are off from school that day (check the local school calendar).
Next, prepare a postcard to be mailed to all patients on the lists your EMR produced for you. Keep the postcard simple. Announce the program, and state the dates the flu shot program is running. Ask parents to call to make an appointment for a flu vaccine only by appointment “with the program.” In addition to mailing a postcard, announce the flu shot program by sending out automated telephone calls and emails to all three lists the EMR has produced for you. The postcard mailing is your first contact, essentially announcing the program with dates and times. An automated phone call may be used to announce a specific date for which you are “now booking.” A good option when using automated phone calls is to allow the caller to press “zero” to be connected to the office to schedule a “flu shot only” appointment! Finally, emails announcing the dates of the program simply will reinforce information about the program.
Mr. Berman has been providing practice management services to physicians and other medical providers since 1983. He is the CEO of a pediatrics practice with locations in Staten Island and Brooklyn, N.Y. He holds a faculty appointment at State University of New York, Brooklyn, as a lecturer for the department of family medicine’s residency training program. He has no disclosures to report. Email him at [email protected].
. It won’t hurt your bottom line either and actually will help it. A flu shot program potentially can be run by a licensed practical nurse, registered nurse, physician’s assistant, or pediatric nurse practitioner, depending on your state’s law regarding vaccine administration by other than a physician, thus freeing up the physician to see well-child and sick-call patients.
It’s easy to set up a flu shot program and run it. Start preparing in June, preceding the upcoming flu season. Designate several Saturdays and or Sundays in September, October, November, December, and January as flu shot Saturdays and/or Sundays. And if Columbus day falls on a weekday, consider adding Columbus Day to your program dates as the kids often are off from school that day (check the local school calendar).
Next, prepare a postcard to be mailed to all patients on the lists your EMR produced for you. Keep the postcard simple. Announce the program, and state the dates the flu shot program is running. Ask parents to call to make an appointment for a flu vaccine only by appointment “with the program.” In addition to mailing a postcard, announce the flu shot program by sending out automated telephone calls and emails to all three lists the EMR has produced for you. The postcard mailing is your first contact, essentially announcing the program with dates and times. An automated phone call may be used to announce a specific date for which you are “now booking.” A good option when using automated phone calls is to allow the caller to press “zero” to be connected to the office to schedule a “flu shot only” appointment! Finally, emails announcing the dates of the program simply will reinforce information about the program.
Mr. Berman has been providing practice management services to physicians and other medical providers since 1983. He is the CEO of a pediatrics practice with locations in Staten Island and Brooklyn, N.Y. He holds a faculty appointment at State University of New York, Brooklyn, as a lecturer for the department of family medicine’s residency training program. He has no disclosures to report. Email him at [email protected].
Systems biology – A primer
Systems biology is relatively new. It is an interdisciplinary field that focuses on complex interactions within biological systems using a holistic approach in the pursuit of scientific discovery.
The systems biology approach seeks to integrate biological knowledge to understand how cells and molecules interact with one another. A key component is computational and mathematical modeling. The ever-increasing amount of biological data, and the judgment that this data cannot be understood by simply drawing lines between interacting cells and molecules, explains the demand for a systematic approach.
Prominent examples for biological systems are the immune system and the nervous system, which already have the word ”system” included. Although the idea of system-level understanding is not new, the growing interest in applying the systems approach has been driven by breakthrough advances in molecular biology and bioinformatics.
Over the past 10 years, our group has identified highly significant differences in immune functioning between the 10% of children who frequently develop acute otitis media (i.e., those who are “otitis prone”) and the children who develop AOM infrequently (60% of children) or not at all (30% of children). We also have identified a cohort of about 10% of children who fail to respond to infant vaccinations (low vaccine responders), compared with children who respond with protective immunity and establishment of immune memory. The differences in children who are prone to AOM vs. those who are not and in low vaccine responders vs. normal vaccine responders include differences in cytokine molecules in blood (providing biosignatures), reduced antibodies, immune memory, and aberrant intercellular signaling networks after otopathogen exposure (AOM prone vs. non–AOM prone) and routine pediatric vaccination (low vs. normal vaccine responders).
Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute at Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. He has no relevant financial disclosures. Email him at [email protected].
Systems biology is relatively new. It is an interdisciplinary field that focuses on complex interactions within biological systems using a holistic approach in the pursuit of scientific discovery.
The systems biology approach seeks to integrate biological knowledge to understand how cells and molecules interact with one another. A key component is computational and mathematical modeling. The ever-increasing amount of biological data, and the judgment that this data cannot be understood by simply drawing lines between interacting cells and molecules, explains the demand for a systematic approach.
Prominent examples for biological systems are the immune system and the nervous system, which already have the word ”system” included. Although the idea of system-level understanding is not new, the growing interest in applying the systems approach has been driven by breakthrough advances in molecular biology and bioinformatics.
Over the past 10 years, our group has identified highly significant differences in immune functioning between the 10% of children who frequently develop acute otitis media (i.e., those who are “otitis prone”) and the children who develop AOM infrequently (60% of children) or not at all (30% of children). We also have identified a cohort of about 10% of children who fail to respond to infant vaccinations (low vaccine responders), compared with children who respond with protective immunity and establishment of immune memory. The differences in children who are prone to AOM vs. those who are not and in low vaccine responders vs. normal vaccine responders include differences in cytokine molecules in blood (providing biosignatures), reduced antibodies, immune memory, and aberrant intercellular signaling networks after otopathogen exposure (AOM prone vs. non–AOM prone) and routine pediatric vaccination (low vs. normal vaccine responders).
Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute at Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. He has no relevant financial disclosures. Email him at [email protected].
Systems biology is relatively new. It is an interdisciplinary field that focuses on complex interactions within biological systems using a holistic approach in the pursuit of scientific discovery.
The systems biology approach seeks to integrate biological knowledge to understand how cells and molecules interact with one another. A key component is computational and mathematical modeling. The ever-increasing amount of biological data, and the judgment that this data cannot be understood by simply drawing lines between interacting cells and molecules, explains the demand for a systematic approach.
Prominent examples for biological systems are the immune system and the nervous system, which already have the word ”system” included. Although the idea of system-level understanding is not new, the growing interest in applying the systems approach has been driven by breakthrough advances in molecular biology and bioinformatics.
Over the past 10 years, our group has identified highly significant differences in immune functioning between the 10% of children who frequently develop acute otitis media (i.e., those who are “otitis prone”) and the children who develop AOM infrequently (60% of children) or not at all (30% of children). We also have identified a cohort of about 10% of children who fail to respond to infant vaccinations (low vaccine responders), compared with children who respond with protective immunity and establishment of immune memory. The differences in children who are prone to AOM vs. those who are not and in low vaccine responders vs. normal vaccine responders include differences in cytokine molecules in blood (providing biosignatures), reduced antibodies, immune memory, and aberrant intercellular signaling networks after otopathogen exposure (AOM prone vs. non–AOM prone) and routine pediatric vaccination (low vs. normal vaccine responders).
Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute at Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. He has no relevant financial disclosures. Email him at [email protected].
Health care panhandlers: A symptom of our system’s baked-in pressures?
A few nights a week after work I have to stop by the store for this or that.
In the last 1-2 months there’s always been a couple at the parking lot exit, both in wheelchairs, with a big sign asking for money to help one of them beat cancer. They even have the amount listed.
But, by the same token, they could be quite legitimate. The American health care system is full of cracks that seriously ill people can slip through. One recent survey found that about 30% of Americans had trouble paying their medical bills.
It’s easy to look at people like this and think, “I’ll never let that happen to me.” We assume they must be smokers, or irresponsible spenders, or some other reason that makes us feel we won’t stumble into the same pitfalls. That’s reassuring, and sometimes true, but not always. And probably more often than we want to realize.
The world is full of people and families devastated by bad luck. Through no fault of their own, they develop a terrible medical condition or suffer grievous injuries, and suddenly, decent, hard-working, previously healthy people are facing foreclosure and financial ruin. It could, quite literally, be any of us.
Case in point: My family has good insurance and has averaged $10,000 in out-of-pocket medical expenses per year for the last several years. That’s for routine stuff: meeting deductibles, copays on medications, tests, and doctor visits, a few ER trips, etc. The only real “surprise” in there was when my wife broke her leg and needed surgery.
If the panhandlers really did have legitimate medical issues, I might be willing to help out. I give to charity. My grandmother and parents stressed that value to me, and I try to teach it to my kids. But, sadly, we live in a world full of con artists who try to make money by taking advantage of caring peoples’ feelings. Look at all the scams that immediately cropped up following the recent hurricane and wildfire disasters. Without knowing the truth, I’d rather give to an organization like the Salvation Army or Red Cross, hoping they have more experience than I do in sorting out who’s really in need.
As a doctor, I also try to justify it by thinking about how much care I do for “free.” This includes uninsured hospital patients we all see on call, knowing we’ll end up writing their bill off as a loss, and bounced checks for copays and deductible portions that we know we’ll never see.
But, no matter how I try to rationalize it, it still bothers me when I see them sitting there as I leave the store. I don’t know if they’re legitimate. But if they are, they aren’t alone, and there’s something seriously wrong with our health care system.
[polldaddy:9876776]
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
A few nights a week after work I have to stop by the store for this or that.
In the last 1-2 months there’s always been a couple at the parking lot exit, both in wheelchairs, with a big sign asking for money to help one of them beat cancer. They even have the amount listed.
But, by the same token, they could be quite legitimate. The American health care system is full of cracks that seriously ill people can slip through. One recent survey found that about 30% of Americans had trouble paying their medical bills.
It’s easy to look at people like this and think, “I’ll never let that happen to me.” We assume they must be smokers, or irresponsible spenders, or some other reason that makes us feel we won’t stumble into the same pitfalls. That’s reassuring, and sometimes true, but not always. And probably more often than we want to realize.
The world is full of people and families devastated by bad luck. Through no fault of their own, they develop a terrible medical condition or suffer grievous injuries, and suddenly, decent, hard-working, previously healthy people are facing foreclosure and financial ruin. It could, quite literally, be any of us.
Case in point: My family has good insurance and has averaged $10,000 in out-of-pocket medical expenses per year for the last several years. That’s for routine stuff: meeting deductibles, copays on medications, tests, and doctor visits, a few ER trips, etc. The only real “surprise” in there was when my wife broke her leg and needed surgery.
If the panhandlers really did have legitimate medical issues, I might be willing to help out. I give to charity. My grandmother and parents stressed that value to me, and I try to teach it to my kids. But, sadly, we live in a world full of con artists who try to make money by taking advantage of caring peoples’ feelings. Look at all the scams that immediately cropped up following the recent hurricane and wildfire disasters. Without knowing the truth, I’d rather give to an organization like the Salvation Army or Red Cross, hoping they have more experience than I do in sorting out who’s really in need.
As a doctor, I also try to justify it by thinking about how much care I do for “free.” This includes uninsured hospital patients we all see on call, knowing we’ll end up writing their bill off as a loss, and bounced checks for copays and deductible portions that we know we’ll never see.
But, no matter how I try to rationalize it, it still bothers me when I see them sitting there as I leave the store. I don’t know if they’re legitimate. But if they are, they aren’t alone, and there’s something seriously wrong with our health care system.
[polldaddy:9876776]
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
A few nights a week after work I have to stop by the store for this or that.
In the last 1-2 months there’s always been a couple at the parking lot exit, both in wheelchairs, with a big sign asking for money to help one of them beat cancer. They even have the amount listed.
But, by the same token, they could be quite legitimate. The American health care system is full of cracks that seriously ill people can slip through. One recent survey found that about 30% of Americans had trouble paying their medical bills.
It’s easy to look at people like this and think, “I’ll never let that happen to me.” We assume they must be smokers, or irresponsible spenders, or some other reason that makes us feel we won’t stumble into the same pitfalls. That’s reassuring, and sometimes true, but not always. And probably more often than we want to realize.
The world is full of people and families devastated by bad luck. Through no fault of their own, they develop a terrible medical condition or suffer grievous injuries, and suddenly, decent, hard-working, previously healthy people are facing foreclosure and financial ruin. It could, quite literally, be any of us.
Case in point: My family has good insurance and has averaged $10,000 in out-of-pocket medical expenses per year for the last several years. That’s for routine stuff: meeting deductibles, copays on medications, tests, and doctor visits, a few ER trips, etc. The only real “surprise” in there was when my wife broke her leg and needed surgery.
If the panhandlers really did have legitimate medical issues, I might be willing to help out. I give to charity. My grandmother and parents stressed that value to me, and I try to teach it to my kids. But, sadly, we live in a world full of con artists who try to make money by taking advantage of caring peoples’ feelings. Look at all the scams that immediately cropped up following the recent hurricane and wildfire disasters. Without knowing the truth, I’d rather give to an organization like the Salvation Army or Red Cross, hoping they have more experience than I do in sorting out who’s really in need.
As a doctor, I also try to justify it by thinking about how much care I do for “free.” This includes uninsured hospital patients we all see on call, knowing we’ll end up writing their bill off as a loss, and bounced checks for copays and deductible portions that we know we’ll never see.
But, no matter how I try to rationalize it, it still bothers me when I see them sitting there as I leave the store. I don’t know if they’re legitimate. But if they are, they aren’t alone, and there’s something seriously wrong with our health care system.
[polldaddy:9876776]
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Your online reputation
Have you ever run across an unfair or even malicious comment about you or your practice on one of those “doctor-rating” web sites? Some curmudgeon, angry about something totally irrelevant to your clinical skills, decided to publicly trash you; and the site, of course, made no effort to authenticate the writer or fact-check the complaint.
What to do? You could hire one of the many companies in the rapidly burgeoning field of online reputation management; but that can cost hundreds to thousands of dollars per month for monitoring and intervention, and there are no guarantees of success.
Leave design and SEO to the pros, but don’t delegate the content itself; as captain of the ship you are responsible for all the facts and opinions on your site. And remember that, once it’s online, it’s online forever; consider the ramifications of anything you post on any site – yours or others – before hitting the “send” button. “The most damaging item about you,” one consultant told me, “could well be something you posted yourself.” Just ask any of several prominent politicians who have famously sabotaged their own careers online.
That said, don’t be shy about creating content. Patients appreciate factual information, but they value your opinions too. Add a blog to your web site and write about subjects – medical and otherwise – that interest you. If you have expertise in a particular field, be sure to write about that.
Incidentally, if the URL for your web site is not your own name, you should register your name as a separate domain name – even if you never use it – to be sure that a trickster or troll, or someone with the same name but a bad reputation, doesn’t get it.
A web site is a powerful resource, but not the only one. Take advantage of Google’s free profiling tool at https://profiles.google.com/me, where you can create a sterling bio, complete with links to URLs, photos, and anything else that shows you in the best possible light. Your Google profile will, of course, be at or near the top of any Google search.
Wikipedia articles also go to the top of most searches, so if you’re notable enough to merit mention in one – or to have one of your own – see that it is done and updated regularly. Remember that Wikipedia’s conflict of interest rules forbid adding or editing content about yourself, so someone with a theoretically “neutral point of view” will have to do it for you.
Other useful resources are the social networking sites. Whatever your opinion of online networks, the reality is that personal pages on Facebook, LinkedIn, and Twitter rank very high on major search engines. (Some consultants say a favorable LinkedIn profile is particularly helpful because of that site’s reputation as a “professional” network.) Make your (noncontroversial) opinions known on these portals. Your community activities, charitable work, interesting hobbies – anything that casts you in a favorable light – also need to be mentioned prominently.
Set up an RSS news feed for yourself (directions to follow in the next two columns), so you’ll know immediately if your name pops up in news or gossip sites, or on blogs. If something untrue is posted about you, take action. Reputable news sites and blogs have their own reputations to protect and can usually be persuaded to correct anything that is demonstrably false. Try to get the error removed entirely or corrected within the original article. An erratum on the last page of the next edition will be ignored and will leave the false information online, intact.
Doctor-rating sites typically refuse to remove unfair comments unless they are blatantly libelous or a case of mistaken identity; but there is nothing wrong with encouraging happy patients to post favorable reviews on those sites. Sauce for the goose, and all that.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
Have you ever run across an unfair or even malicious comment about you or your practice on one of those “doctor-rating” web sites? Some curmudgeon, angry about something totally irrelevant to your clinical skills, decided to publicly trash you; and the site, of course, made no effort to authenticate the writer or fact-check the complaint.
What to do? You could hire one of the many companies in the rapidly burgeoning field of online reputation management; but that can cost hundreds to thousands of dollars per month for monitoring and intervention, and there are no guarantees of success.
Leave design and SEO to the pros, but don’t delegate the content itself; as captain of the ship you are responsible for all the facts and opinions on your site. And remember that, once it’s online, it’s online forever; consider the ramifications of anything you post on any site – yours or others – before hitting the “send” button. “The most damaging item about you,” one consultant told me, “could well be something you posted yourself.” Just ask any of several prominent politicians who have famously sabotaged their own careers online.
That said, don’t be shy about creating content. Patients appreciate factual information, but they value your opinions too. Add a blog to your web site and write about subjects – medical and otherwise – that interest you. If you have expertise in a particular field, be sure to write about that.
Incidentally, if the URL for your web site is not your own name, you should register your name as a separate domain name – even if you never use it – to be sure that a trickster or troll, or someone with the same name but a bad reputation, doesn’t get it.
A web site is a powerful resource, but not the only one. Take advantage of Google’s free profiling tool at https://profiles.google.com/me, where you can create a sterling bio, complete with links to URLs, photos, and anything else that shows you in the best possible light. Your Google profile will, of course, be at or near the top of any Google search.
Wikipedia articles also go to the top of most searches, so if you’re notable enough to merit mention in one – or to have one of your own – see that it is done and updated regularly. Remember that Wikipedia’s conflict of interest rules forbid adding or editing content about yourself, so someone with a theoretically “neutral point of view” will have to do it for you.
Other useful resources are the social networking sites. Whatever your opinion of online networks, the reality is that personal pages on Facebook, LinkedIn, and Twitter rank very high on major search engines. (Some consultants say a favorable LinkedIn profile is particularly helpful because of that site’s reputation as a “professional” network.) Make your (noncontroversial) opinions known on these portals. Your community activities, charitable work, interesting hobbies – anything that casts you in a favorable light – also need to be mentioned prominently.
Set up an RSS news feed for yourself (directions to follow in the next two columns), so you’ll know immediately if your name pops up in news or gossip sites, or on blogs. If something untrue is posted about you, take action. Reputable news sites and blogs have their own reputations to protect and can usually be persuaded to correct anything that is demonstrably false. Try to get the error removed entirely or corrected within the original article. An erratum on the last page of the next edition will be ignored and will leave the false information online, intact.
Doctor-rating sites typically refuse to remove unfair comments unless they are blatantly libelous or a case of mistaken identity; but there is nothing wrong with encouraging happy patients to post favorable reviews on those sites. Sauce for the goose, and all that.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
Have you ever run across an unfair or even malicious comment about you or your practice on one of those “doctor-rating” web sites? Some curmudgeon, angry about something totally irrelevant to your clinical skills, decided to publicly trash you; and the site, of course, made no effort to authenticate the writer or fact-check the complaint.
What to do? You could hire one of the many companies in the rapidly burgeoning field of online reputation management; but that can cost hundreds to thousands of dollars per month for monitoring and intervention, and there are no guarantees of success.
Leave design and SEO to the pros, but don’t delegate the content itself; as captain of the ship you are responsible for all the facts and opinions on your site. And remember that, once it’s online, it’s online forever; consider the ramifications of anything you post on any site – yours or others – before hitting the “send” button. “The most damaging item about you,” one consultant told me, “could well be something you posted yourself.” Just ask any of several prominent politicians who have famously sabotaged their own careers online.
That said, don’t be shy about creating content. Patients appreciate factual information, but they value your opinions too. Add a blog to your web site and write about subjects – medical and otherwise – that interest you. If you have expertise in a particular field, be sure to write about that.
Incidentally, if the URL for your web site is not your own name, you should register your name as a separate domain name – even if you never use it – to be sure that a trickster or troll, or someone with the same name but a bad reputation, doesn’t get it.
A web site is a powerful resource, but not the only one. Take advantage of Google’s free profiling tool at https://profiles.google.com/me, where you can create a sterling bio, complete with links to URLs, photos, and anything else that shows you in the best possible light. Your Google profile will, of course, be at or near the top of any Google search.
Wikipedia articles also go to the top of most searches, so if you’re notable enough to merit mention in one – or to have one of your own – see that it is done and updated regularly. Remember that Wikipedia’s conflict of interest rules forbid adding or editing content about yourself, so someone with a theoretically “neutral point of view” will have to do it for you.
Other useful resources are the social networking sites. Whatever your opinion of online networks, the reality is that personal pages on Facebook, LinkedIn, and Twitter rank very high on major search engines. (Some consultants say a favorable LinkedIn profile is particularly helpful because of that site’s reputation as a “professional” network.) Make your (noncontroversial) opinions known on these portals. Your community activities, charitable work, interesting hobbies – anything that casts you in a favorable light – also need to be mentioned prominently.
Set up an RSS news feed for yourself (directions to follow in the next two columns), so you’ll know immediately if your name pops up in news or gossip sites, or on blogs. If something untrue is posted about you, take action. Reputable news sites and blogs have their own reputations to protect and can usually be persuaded to correct anything that is demonstrably false. Try to get the error removed entirely or corrected within the original article. An erratum on the last page of the next edition will be ignored and will leave the false information online, intact.
Doctor-rating sites typically refuse to remove unfair comments unless they are blatantly libelous or a case of mistaken identity; but there is nothing wrong with encouraging happy patients to post favorable reviews on those sites. Sauce for the goose, and all that.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
Personality disorders and the court system
As forensic psychiatrists, one of our main roles is to apply the Dusky standard to assess competency. In this regard, multiple times a week, we see pretrial defendants who wait weeks, sometimes months, in jail, for their competency evaluations. Will they be permitted to attend court and continue with their legal proceedings, or will a judge remand them into an involuntary treatment unit to restore their competency? The number of defendants referred for competency evaluation is formally not measured, but estimates suggest it almost doubled from 19731 till 2000.2
The intent of ensuring the competency of the accused is fundamentally fair. While all would agree that only those who are convicted of committing crimes be found guilty, not every culture has paid attention to the question of whether those found guilty understand how and why that happened.
The Dusky standards come from the landmark U.S. Supreme Court case of Dusky v. United States in 1960. Milton Dusky faced charges of kidnapping an underage female across state lines and raping her. Despite psychiatric testimony that the defendant could not “properly assist” his counsel because of a delusion that he was framed, the court found him competent and convicted him to a 45-year sentence. The case was appealed all the way to the Supreme Court, which held that the fact that Dusky was oriented and remembered the events was not enough to establish competency. The Supreme Court stated that the test for competency was the ability to consult with a lawyer with “a reasonable degree of rational understanding” and a “factual as well as rational understanding of the proceedings.” The Dusky ruling did not comment on what conditions may make a person incompetent to stand trial.3
With the increase in referrals for competency, we have noted an expansion in the kind of referrals we receive. In a hospital setting, physicians often comment that referrals for capacity evaluations stem from the patient’s disagreement with her/his attending physician about treatment, not a lack of understanding of the treatment options. Similarly, many referrals we receive for evaluation of competency to stand trial seem generated by interpersonal difficulties rather than insufficient rational and factual knowledge. In this article, we will review a case seen in our clinic five times over a period of 7 years. Over that time frame, the defendant was incarcerated 10 times and referred 5 times for a competency evaluation. We have changed key facts about the defendant and his case to protect his confidentiality.
Defendant’s background
The defendant is a 40-something-year-old man who vacillates between homelessness and living with friends who partake in his penchant for alcohol. He has committed various crimes, including thefts, disorderly conduct, and possession of controlled substances. He went to prison once for selling narcotics but quickly retorts: “I don’t sell … . This [expletive] cop came and asked if I had any. She was hot. What did you want me to say? It was entrapment.”
However, to get this defendant to have a conversation is no simple task. On his way to the professional visit area, he was livid with a deputy about not receiving an entire breakfast tray earlier in the morning. When he sat down for the interview, he initially yelled for 10 minutes without interruption. His speech was full of profanities and demeaning comments about our ethnic background, education, and expertise. After about 15 minutes and numerous attempts at inserting a question or a comment, I said: “I do not think that you have evidenced a lack of competency, and you are not engaging with me. I am leaving. Thank you for your time.” He shouted two more times, then stopped, smiled, and said: “I was just testing you. Relax, doc.” He subsequently answered all of my questions with his usual jokes and a calm demeanor.
Once he engaged in the interview, he was able to provide a factual and rational description of his charge, which was, “criminal threat.” “I was at the bus station with my knife; I was playing with it; I was not threatening anyone. Then this [racial expletive] cop comes and tells me that I am under arrest.”
Challenging behavior continues
During the course of the interview, he was able to demonstrate that he understands the meaning of making a threat, of committing a crime, and of the roles of the different courtroom personnel. However, the stress of court highlights his interpersonal problems. In this particular case, he recounts: “Court had not yet started; I was talking to my lawyer, and the judge interrupted me, so I answered: Wait your turn [expletive] … not my greatest idea.” When asked about his past referral for competency, he mentions it was in response to trying to fire a public defender because “she was Mexican. I don’t work with those.”
Given his behavior, it is unclear how else a judge or a lawyer could have acted. One could argue that it would be a mistake not to refer this defendant for a competency evaluation, considering his outbursts. On the other hand, he had been evaluated many times before, and the opinion of well-respected forensic psychiatrists was that he did not have a mental illness.
While we reflect on our experience with this defendant, we are unsure of the lessons to be learned. We ponder whether psychiatry does a disservice when not being clearer about what constitutes a serious mental illness. We wonder if we exacerbated the confusion by the removal of “Axis II” categories from the DSM, implying that severe personality disorders are no longer different from, say, schizophrenia and bipolar disorder. Rarely do we hear psychiatrists point out that unusual behaviors do not equal mental illness. We are often too pleased in advocating for more resources by saying that all crimes, all substance misuses, and all annoying behaviors are forms of mental illness when, in reality, the criminal4, the addictive5, and the less common6 are not always biologically based mental disorders or even the real problem, for that matter.
This defendant is difficult. He argues, he yells, he provokes, and he hurts others physically as well as emotionally. While many psychiatrists have decided to codify this pattern of behavior within the B cluster of personality traits, have we misled the public into thinking that patients with personality disorders require the same attention and care as patients with other forms of mental illness, like schizophrenia? Often, we see patients with schizophrenia, bipolar depression, or major depression, who even at their best, are too impaired to file their taxes, apply for an identity card, or understand the complexity of the legal system.
Psychiatry’s difficulty in verbalizing the difference between those disorders harms the public perception of mental disorders. As a result, we have a forensic system similar to the rest of the community health care system – with an abundance of individuals with severe mental illness not referred for treatment or evaluation, and several patients with personality disorders bogging down a system with very limited resources. It is our responsibility not only to educate the public on how to manage and contain the emotions that patients with personality disorders engender in us, but also to educate the public on how to recognize patients with profound mentally ill patients who are quietly suffering.
Dr. Badre is affiliated with the county of San Diego, the University of California at San Diego, and the University of San Diego. Dr. Rao is a San Diego–based board-certified psychiatrist with expertise in forensic psychiatry, correctional psychiatry, telepsychiatry, and inpatient psychiatry.
References
1. Competency to Stand Trial and Mental Illness: Final Report. Rockville, Md.: National Institute of Mental Health, 1973.
2. Youth on Trial: A Developmental Perspective on Juvenile Justice. Chicago: University of Chicago Press, 2000.
3. J Am Acad Psychiatry Law. 2007;35(4 Suppl):S3-72.
4. Clin Psychiatry News. 2017;45(8):5.
5. Law and Philosophy. 1999;18(6):589-610.
6. Am J Psychiatry. 1981 Feb;138(2):210-5.
As forensic psychiatrists, one of our main roles is to apply the Dusky standard to assess competency. In this regard, multiple times a week, we see pretrial defendants who wait weeks, sometimes months, in jail, for their competency evaluations. Will they be permitted to attend court and continue with their legal proceedings, or will a judge remand them into an involuntary treatment unit to restore their competency? The number of defendants referred for competency evaluation is formally not measured, but estimates suggest it almost doubled from 19731 till 2000.2
The intent of ensuring the competency of the accused is fundamentally fair. While all would agree that only those who are convicted of committing crimes be found guilty, not every culture has paid attention to the question of whether those found guilty understand how and why that happened.
The Dusky standards come from the landmark U.S. Supreme Court case of Dusky v. United States in 1960. Milton Dusky faced charges of kidnapping an underage female across state lines and raping her. Despite psychiatric testimony that the defendant could not “properly assist” his counsel because of a delusion that he was framed, the court found him competent and convicted him to a 45-year sentence. The case was appealed all the way to the Supreme Court, which held that the fact that Dusky was oriented and remembered the events was not enough to establish competency. The Supreme Court stated that the test for competency was the ability to consult with a lawyer with “a reasonable degree of rational understanding” and a “factual as well as rational understanding of the proceedings.” The Dusky ruling did not comment on what conditions may make a person incompetent to stand trial.3
With the increase in referrals for competency, we have noted an expansion in the kind of referrals we receive. In a hospital setting, physicians often comment that referrals for capacity evaluations stem from the patient’s disagreement with her/his attending physician about treatment, not a lack of understanding of the treatment options. Similarly, many referrals we receive for evaluation of competency to stand trial seem generated by interpersonal difficulties rather than insufficient rational and factual knowledge. In this article, we will review a case seen in our clinic five times over a period of 7 years. Over that time frame, the defendant was incarcerated 10 times and referred 5 times for a competency evaluation. We have changed key facts about the defendant and his case to protect his confidentiality.
Defendant’s background
The defendant is a 40-something-year-old man who vacillates between homelessness and living with friends who partake in his penchant for alcohol. He has committed various crimes, including thefts, disorderly conduct, and possession of controlled substances. He went to prison once for selling narcotics but quickly retorts: “I don’t sell … . This [expletive] cop came and asked if I had any. She was hot. What did you want me to say? It was entrapment.”
However, to get this defendant to have a conversation is no simple task. On his way to the professional visit area, he was livid with a deputy about not receiving an entire breakfast tray earlier in the morning. When he sat down for the interview, he initially yelled for 10 minutes without interruption. His speech was full of profanities and demeaning comments about our ethnic background, education, and expertise. After about 15 minutes and numerous attempts at inserting a question or a comment, I said: “I do not think that you have evidenced a lack of competency, and you are not engaging with me. I am leaving. Thank you for your time.” He shouted two more times, then stopped, smiled, and said: “I was just testing you. Relax, doc.” He subsequently answered all of my questions with his usual jokes and a calm demeanor.
Once he engaged in the interview, he was able to provide a factual and rational description of his charge, which was, “criminal threat.” “I was at the bus station with my knife; I was playing with it; I was not threatening anyone. Then this [racial expletive] cop comes and tells me that I am under arrest.”
Challenging behavior continues
During the course of the interview, he was able to demonstrate that he understands the meaning of making a threat, of committing a crime, and of the roles of the different courtroom personnel. However, the stress of court highlights his interpersonal problems. In this particular case, he recounts: “Court had not yet started; I was talking to my lawyer, and the judge interrupted me, so I answered: Wait your turn [expletive] … not my greatest idea.” When asked about his past referral for competency, he mentions it was in response to trying to fire a public defender because “she was Mexican. I don’t work with those.”
Given his behavior, it is unclear how else a judge or a lawyer could have acted. One could argue that it would be a mistake not to refer this defendant for a competency evaluation, considering his outbursts. On the other hand, he had been evaluated many times before, and the opinion of well-respected forensic psychiatrists was that he did not have a mental illness.
While we reflect on our experience with this defendant, we are unsure of the lessons to be learned. We ponder whether psychiatry does a disservice when not being clearer about what constitutes a serious mental illness. We wonder if we exacerbated the confusion by the removal of “Axis II” categories from the DSM, implying that severe personality disorders are no longer different from, say, schizophrenia and bipolar disorder. Rarely do we hear psychiatrists point out that unusual behaviors do not equal mental illness. We are often too pleased in advocating for more resources by saying that all crimes, all substance misuses, and all annoying behaviors are forms of mental illness when, in reality, the criminal4, the addictive5, and the less common6 are not always biologically based mental disorders or even the real problem, for that matter.
This defendant is difficult. He argues, he yells, he provokes, and he hurts others physically as well as emotionally. While many psychiatrists have decided to codify this pattern of behavior within the B cluster of personality traits, have we misled the public into thinking that patients with personality disorders require the same attention and care as patients with other forms of mental illness, like schizophrenia? Often, we see patients with schizophrenia, bipolar depression, or major depression, who even at their best, are too impaired to file their taxes, apply for an identity card, or understand the complexity of the legal system.
Psychiatry’s difficulty in verbalizing the difference between those disorders harms the public perception of mental disorders. As a result, we have a forensic system similar to the rest of the community health care system – with an abundance of individuals with severe mental illness not referred for treatment or evaluation, and several patients with personality disorders bogging down a system with very limited resources. It is our responsibility not only to educate the public on how to manage and contain the emotions that patients with personality disorders engender in us, but also to educate the public on how to recognize patients with profound mentally ill patients who are quietly suffering.
Dr. Badre is affiliated with the county of San Diego, the University of California at San Diego, and the University of San Diego. Dr. Rao is a San Diego–based board-certified psychiatrist with expertise in forensic psychiatry, correctional psychiatry, telepsychiatry, and inpatient psychiatry.
References
1. Competency to Stand Trial and Mental Illness: Final Report. Rockville, Md.: National Institute of Mental Health, 1973.
2. Youth on Trial: A Developmental Perspective on Juvenile Justice. Chicago: University of Chicago Press, 2000.
3. J Am Acad Psychiatry Law. 2007;35(4 Suppl):S3-72.
4. Clin Psychiatry News. 2017;45(8):5.
5. Law and Philosophy. 1999;18(6):589-610.
6. Am J Psychiatry. 1981 Feb;138(2):210-5.
As forensic psychiatrists, one of our main roles is to apply the Dusky standard to assess competency. In this regard, multiple times a week, we see pretrial defendants who wait weeks, sometimes months, in jail, for their competency evaluations. Will they be permitted to attend court and continue with their legal proceedings, or will a judge remand them into an involuntary treatment unit to restore their competency? The number of defendants referred for competency evaluation is formally not measured, but estimates suggest it almost doubled from 19731 till 2000.2
The intent of ensuring the competency of the accused is fundamentally fair. While all would agree that only those who are convicted of committing crimes be found guilty, not every culture has paid attention to the question of whether those found guilty understand how and why that happened.
The Dusky standards come from the landmark U.S. Supreme Court case of Dusky v. United States in 1960. Milton Dusky faced charges of kidnapping an underage female across state lines and raping her. Despite psychiatric testimony that the defendant could not “properly assist” his counsel because of a delusion that he was framed, the court found him competent and convicted him to a 45-year sentence. The case was appealed all the way to the Supreme Court, which held that the fact that Dusky was oriented and remembered the events was not enough to establish competency. The Supreme Court stated that the test for competency was the ability to consult with a lawyer with “a reasonable degree of rational understanding” and a “factual as well as rational understanding of the proceedings.” The Dusky ruling did not comment on what conditions may make a person incompetent to stand trial.3
With the increase in referrals for competency, we have noted an expansion in the kind of referrals we receive. In a hospital setting, physicians often comment that referrals for capacity evaluations stem from the patient’s disagreement with her/his attending physician about treatment, not a lack of understanding of the treatment options. Similarly, many referrals we receive for evaluation of competency to stand trial seem generated by interpersonal difficulties rather than insufficient rational and factual knowledge. In this article, we will review a case seen in our clinic five times over a period of 7 years. Over that time frame, the defendant was incarcerated 10 times and referred 5 times for a competency evaluation. We have changed key facts about the defendant and his case to protect his confidentiality.
Defendant’s background
The defendant is a 40-something-year-old man who vacillates between homelessness and living with friends who partake in his penchant for alcohol. He has committed various crimes, including thefts, disorderly conduct, and possession of controlled substances. He went to prison once for selling narcotics but quickly retorts: “I don’t sell … . This [expletive] cop came and asked if I had any. She was hot. What did you want me to say? It was entrapment.”
However, to get this defendant to have a conversation is no simple task. On his way to the professional visit area, he was livid with a deputy about not receiving an entire breakfast tray earlier in the morning. When he sat down for the interview, he initially yelled for 10 minutes without interruption. His speech was full of profanities and demeaning comments about our ethnic background, education, and expertise. After about 15 minutes and numerous attempts at inserting a question or a comment, I said: “I do not think that you have evidenced a lack of competency, and you are not engaging with me. I am leaving. Thank you for your time.” He shouted two more times, then stopped, smiled, and said: “I was just testing you. Relax, doc.” He subsequently answered all of my questions with his usual jokes and a calm demeanor.
Once he engaged in the interview, he was able to provide a factual and rational description of his charge, which was, “criminal threat.” “I was at the bus station with my knife; I was playing with it; I was not threatening anyone. Then this [racial expletive] cop comes and tells me that I am under arrest.”
Challenging behavior continues
During the course of the interview, he was able to demonstrate that he understands the meaning of making a threat, of committing a crime, and of the roles of the different courtroom personnel. However, the stress of court highlights his interpersonal problems. In this particular case, he recounts: “Court had not yet started; I was talking to my lawyer, and the judge interrupted me, so I answered: Wait your turn [expletive] … not my greatest idea.” When asked about his past referral for competency, he mentions it was in response to trying to fire a public defender because “she was Mexican. I don’t work with those.”
Given his behavior, it is unclear how else a judge or a lawyer could have acted. One could argue that it would be a mistake not to refer this defendant for a competency evaluation, considering his outbursts. On the other hand, he had been evaluated many times before, and the opinion of well-respected forensic psychiatrists was that he did not have a mental illness.
While we reflect on our experience with this defendant, we are unsure of the lessons to be learned. We ponder whether psychiatry does a disservice when not being clearer about what constitutes a serious mental illness. We wonder if we exacerbated the confusion by the removal of “Axis II” categories from the DSM, implying that severe personality disorders are no longer different from, say, schizophrenia and bipolar disorder. Rarely do we hear psychiatrists point out that unusual behaviors do not equal mental illness. We are often too pleased in advocating for more resources by saying that all crimes, all substance misuses, and all annoying behaviors are forms of mental illness when, in reality, the criminal4, the addictive5, and the less common6 are not always biologically based mental disorders or even the real problem, for that matter.
This defendant is difficult. He argues, he yells, he provokes, and he hurts others physically as well as emotionally. While many psychiatrists have decided to codify this pattern of behavior within the B cluster of personality traits, have we misled the public into thinking that patients with personality disorders require the same attention and care as patients with other forms of mental illness, like schizophrenia? Often, we see patients with schizophrenia, bipolar depression, or major depression, who even at their best, are too impaired to file their taxes, apply for an identity card, or understand the complexity of the legal system.
Psychiatry’s difficulty in verbalizing the difference between those disorders harms the public perception of mental disorders. As a result, we have a forensic system similar to the rest of the community health care system – with an abundance of individuals with severe mental illness not referred for treatment or evaluation, and several patients with personality disorders bogging down a system with very limited resources. It is our responsibility not only to educate the public on how to manage and contain the emotions that patients with personality disorders engender in us, but also to educate the public on how to recognize patients with profound mentally ill patients who are quietly suffering.
Dr. Badre is affiliated with the county of San Diego, the University of California at San Diego, and the University of San Diego. Dr. Rao is a San Diego–based board-certified psychiatrist with expertise in forensic psychiatry, correctional psychiatry, telepsychiatry, and inpatient psychiatry.
References
1. Competency to Stand Trial and Mental Illness: Final Report. Rockville, Md.: National Institute of Mental Health, 1973.
2. Youth on Trial: A Developmental Perspective on Juvenile Justice. Chicago: University of Chicago Press, 2000.
3. J Am Acad Psychiatry Law. 2007;35(4 Suppl):S3-72.
4. Clin Psychiatry News. 2017;45(8):5.
5. Law and Philosophy. 1999;18(6):589-610.
6. Am J Psychiatry. 1981 Feb;138(2):210-5.
Natural and Unnatural Disasters
Between late August and early November of this year, three strong Gulf Coast and Atlantic hurricanes and several intense, fast-moving northern California forest fires claimed more than 285 lives and caused countless additional injuries and illnesses. During the same period, three unnatural disasters—in Las Vegas, New York City (NYC), and now Sutherland Springs, Texas—were responsible for a total of 84 deaths and 558 injuries. Emergency physicians (EPs) and our colleagues helped deal with the aftermath of all of these incidents, saving lives and ameliorating survivors’ pain and suffering. But ironically, preventing future deaths and injuries from natural disasters may be easier than preventing loss of life from depraved human behavior.
An October 9, 2017 Wall Street Journal (WSJ) article by Jeanne Whalen entitled “Training Ground for Military Trauma Experts: U.S. Gun Violence,” describes how military surgeons helped treat victims of the Las Vegas shooting, one of several arrangements across the United States where steady gun violence provides a training ground that experts can then use on the battlefield. The article includes a photograph of Tom Scalea, MD, Chief of the R. Adams Cowley (Maryland) Shock Trauma Center and EM board member, operating with the assistance of an Air Force surgeon “embedded” at the hospital.
Before September 11, 2001, US hospitals looked to military surgeons experienced in treating combat injuries to direct and staff their trauma centers. Now, the military looks to US hospitals to provide their surgeons with experience treating victims of gun violence, explosives, and high-speed vehicular injuries prior to sending them into war zones! In the week before this issue of EM went to press, a terrorist driving a rental truck down an NYC bicycle path killed 8 people and injured 11 near the site of the 1993 and 2001 World Trade Center attacks. Five days later, 26 church worshipers near Austin, Texas lost their lives and 20 more were seriously injured when a lone gunman shot them with an assault rifle.
The gun violence statistics in this country are staggering. According to the nonprofit Gun Violence Archive (GVA; http://www.gunviolencearchive.org/), from January 1 through November 8, 2017 there have been 52,719 incidents resulting in 13,245 deaths and 27,111
The pervasiveness of the gun culture in this country offers little hope of eliminating such incidents in the future, which makes it especially important for all EPs to be skilled in state-of-the-art trauma management. (See parts I and II of “The changing landscape of trauma care” in the July and August 2017 issues of EM [www.mdedge.com/emed-journal]). As Baltimore trauma surgeon Tom Scalea notes in the WSJ article cited earlier, “Mass shooting? That’s every weekend.…it makes me despondent….I don’t have the ability to make that go away. I have the ability to keep as many alive as I can, and we’re pretty good at it.”
As for preventing deaths from natural disasters, more accurate weather forecasting and newer technology offer more hope. Among the 134 storm-related deaths from Hurricane Irma in September, 14 were heat-related after the storm disabled a transformer supplying power to the air conditioning system of a Hollywood, Florida nursing home. A new state law will now require all nursing homes to have adequate backup generators. But for the increasing numbers of older persons with comorbidities, taking multiple medications, and living in hot climates, air conditioning must be considered life support equipment that requires immediate repair or replacement when it fails—or transfer of the residents to a cool facility.
If only we could someday also prevent terrorism and other acts of senseless violence.
*The GVA defines a mass shooting as a single incident resulting in 4 or more people (not including the shooter) shot and/or killed at the same general time and location.
Between late August and early November of this year, three strong Gulf Coast and Atlantic hurricanes and several intense, fast-moving northern California forest fires claimed more than 285 lives and caused countless additional injuries and illnesses. During the same period, three unnatural disasters—in Las Vegas, New York City (NYC), and now Sutherland Springs, Texas—were responsible for a total of 84 deaths and 558 injuries. Emergency physicians (EPs) and our colleagues helped deal with the aftermath of all of these incidents, saving lives and ameliorating survivors’ pain and suffering. But ironically, preventing future deaths and injuries from natural disasters may be easier than preventing loss of life from depraved human behavior.
An October 9, 2017 Wall Street Journal (WSJ) article by Jeanne Whalen entitled “Training Ground for Military Trauma Experts: U.S. Gun Violence,” describes how military surgeons helped treat victims of the Las Vegas shooting, one of several arrangements across the United States where steady gun violence provides a training ground that experts can then use on the battlefield. The article includes a photograph of Tom Scalea, MD, Chief of the R. Adams Cowley (Maryland) Shock Trauma Center and EM board member, operating with the assistance of an Air Force surgeon “embedded” at the hospital.
Before September 11, 2001, US hospitals looked to military surgeons experienced in treating combat injuries to direct and staff their trauma centers. Now, the military looks to US hospitals to provide their surgeons with experience treating victims of gun violence, explosives, and high-speed vehicular injuries prior to sending them into war zones! In the week before this issue of EM went to press, a terrorist driving a rental truck down an NYC bicycle path killed 8 people and injured 11 near the site of the 1993 and 2001 World Trade Center attacks. Five days later, 26 church worshipers near Austin, Texas lost their lives and 20 more were seriously injured when a lone gunman shot them with an assault rifle.
The gun violence statistics in this country are staggering. According to the nonprofit Gun Violence Archive (GVA; http://www.gunviolencearchive.org/), from January 1 through November 8, 2017 there have been 52,719 incidents resulting in 13,245 deaths and 27,111
The pervasiveness of the gun culture in this country offers little hope of eliminating such incidents in the future, which makes it especially important for all EPs to be skilled in state-of-the-art trauma management. (See parts I and II of “The changing landscape of trauma care” in the July and August 2017 issues of EM [www.mdedge.com/emed-journal]). As Baltimore trauma surgeon Tom Scalea notes in the WSJ article cited earlier, “Mass shooting? That’s every weekend.…it makes me despondent….I don’t have the ability to make that go away. I have the ability to keep as many alive as I can, and we’re pretty good at it.”
As for preventing deaths from natural disasters, more accurate weather forecasting and newer technology offer more hope. Among the 134 storm-related deaths from Hurricane Irma in September, 14 were heat-related after the storm disabled a transformer supplying power to the air conditioning system of a Hollywood, Florida nursing home. A new state law will now require all nursing homes to have adequate backup generators. But for the increasing numbers of older persons with comorbidities, taking multiple medications, and living in hot climates, air conditioning must be considered life support equipment that requires immediate repair or replacement when it fails—or transfer of the residents to a cool facility.
If only we could someday also prevent terrorism and other acts of senseless violence.
*The GVA defines a mass shooting as a single incident resulting in 4 or more people (not including the shooter) shot and/or killed at the same general time and location.
Between late August and early November of this year, three strong Gulf Coast and Atlantic hurricanes and several intense, fast-moving northern California forest fires claimed more than 285 lives and caused countless additional injuries and illnesses. During the same period, three unnatural disasters—in Las Vegas, New York City (NYC), and now Sutherland Springs, Texas—were responsible for a total of 84 deaths and 558 injuries. Emergency physicians (EPs) and our colleagues helped deal with the aftermath of all of these incidents, saving lives and ameliorating survivors’ pain and suffering. But ironically, preventing future deaths and injuries from natural disasters may be easier than preventing loss of life from depraved human behavior.
An October 9, 2017 Wall Street Journal (WSJ) article by Jeanne Whalen entitled “Training Ground for Military Trauma Experts: U.S. Gun Violence,” describes how military surgeons helped treat victims of the Las Vegas shooting, one of several arrangements across the United States where steady gun violence provides a training ground that experts can then use on the battlefield. The article includes a photograph of Tom Scalea, MD, Chief of the R. Adams Cowley (Maryland) Shock Trauma Center and EM board member, operating with the assistance of an Air Force surgeon “embedded” at the hospital.
Before September 11, 2001, US hospitals looked to military surgeons experienced in treating combat injuries to direct and staff their trauma centers. Now, the military looks to US hospitals to provide their surgeons with experience treating victims of gun violence, explosives, and high-speed vehicular injuries prior to sending them into war zones! In the week before this issue of EM went to press, a terrorist driving a rental truck down an NYC bicycle path killed 8 people and injured 11 near the site of the 1993 and 2001 World Trade Center attacks. Five days later, 26 church worshipers near Austin, Texas lost their lives and 20 more were seriously injured when a lone gunman shot them with an assault rifle.
The gun violence statistics in this country are staggering. According to the nonprofit Gun Violence Archive (GVA; http://www.gunviolencearchive.org/), from January 1 through November 8, 2017 there have been 52,719 incidents resulting in 13,245 deaths and 27,111
The pervasiveness of the gun culture in this country offers little hope of eliminating such incidents in the future, which makes it especially important for all EPs to be skilled in state-of-the-art trauma management. (See parts I and II of “The changing landscape of trauma care” in the July and August 2017 issues of EM [www.mdedge.com/emed-journal]). As Baltimore trauma surgeon Tom Scalea notes in the WSJ article cited earlier, “Mass shooting? That’s every weekend.…it makes me despondent….I don’t have the ability to make that go away. I have the ability to keep as many alive as I can, and we’re pretty good at it.”
As for preventing deaths from natural disasters, more accurate weather forecasting and newer technology offer more hope. Among the 134 storm-related deaths from Hurricane Irma in September, 14 were heat-related after the storm disabled a transformer supplying power to the air conditioning system of a Hollywood, Florida nursing home. A new state law will now require all nursing homes to have adequate backup generators. But for the increasing numbers of older persons with comorbidities, taking multiple medications, and living in hot climates, air conditioning must be considered life support equipment that requires immediate repair or replacement when it fails—or transfer of the residents to a cool facility.
If only we could someday also prevent terrorism and other acts of senseless violence.
*The GVA defines a mass shooting as a single incident resulting in 4 or more people (not including the shooter) shot and/or killed at the same general time and location.
