Teaching forensic psychiatry to general psychiatry residents

World Psychiatric Association-Asian Journal of Psychiatry Commission on Psychiatric Education in the 21st century

Psychiatric practice faces many challenges in the first quarter of 21st century. Society has transformed, as have training requirements and patient expectations, underlining an urgent need to look at educational programmes. Meanwhile, awareness has grown around psychiatric disorders and there are evolving workforce trends, with more women going to medical school and specialising in psychiatry. Trainee psychiatrists carry different expectations for work-life balance and are increasingly becoming conscious of their own mental health. A tendency to see health as a commodity and the litigious nature of society has elicited additional pressures for healthcare professionals. Cartesian mind-body dualism has created further complexity and this can often be frustrating for patients and care-partners alike. In many cultures across Asia and beyond, patients can present with physical symptoms to express underlying psychological distress with increasing physical investigations. Simultaneously, in various countries, a shift from asylums to community-based interventions and then home treatments have changed psychiatric care in remarkable ways. These changes have added to pressures faced by mental healthcare professionals. However, trainees and other mental healthcare professionals continue to receive similar training as they did a generation ago. The tensions and differences in ideology/orientation between different branches of psychiatry have made responses to patient needs challenging. Recognising that it is difficult to predict the future, this World Psychiatric Association-Asian Journal of Psychiatry Commission makes recommendations that could help institutions and individuals enhance psychiatric education. This Commission draws from existing resources and recent developments to propose a training framework for future psychiatrists.

Concepts and controversies of malingering: A re-look

Since time immemorial, humans have tried to feign physical and mental illnesses for various reasons. This led to the development of the concept of illness deception or malingering when one tries to assume a sick role and feigns signs and symptoms to gain external incentives. The conceptual framework of malingering has undergone several changes and there is sufficient evidence to demonstrate that malingering exists. However, the diagnosis of malingering has not yet been established in the mainstream psychiatric nosological systems and still it is present in the appendices as an additional area requiring attention. This is due to the poor construct validity of the diagnosis, problems in defining malingering, problems in assessment by psychological tests and clinical assessment methodology, no well-established guidelines to detect malingering and issues related to labelling/reporting malingering. Because of several controversies in multiple domains of assessment and ethical-social issues, malingering as a distinct entity is grossly neglected. In the upcoming arena of law suits and consumer benefits suits, it is extremely important to have a better understanding of the conceptual issues related to malingering and the controversies related to it. In this review, a brief overview of evolution of concepts and controversies related to malingering is described.

The Benefits of Required Forensic Clinical Experiences in Residency

OBJECTIVE

The growth of forensic psychiatry has spurred efforts to improve forensic psychiatry training in general psychiatry residency. The Accreditation Council for Graduate Medical Education requires that residencies provide an experience that "exposes" residents to forensic issues, but leaves the specifics to individual programs. However, there is growing need for psychiatrists to understand the unique circumstances of individuals with mental illness involved in the criminal justice system.

METHODS

The authors developed a new mandatory forensic rotation for general psychiatry residents and conducted a pilot study to assess its impact on residents' interest and comfort working with criminal justice-involved patients, interest in forensic fellowship, and knowledge of available resources for consultation and supervision.

RESULTS

Rotation completion was associated with a significantly increased interest in working with forensic populations and pursuing forensic fellowship, but no changes in residents' level of comfort or knowledge of supervisory and consultative resources.

CONCLUSIONS

This study adds to the growing body of literature describing the benefits of expanding forensic education for residents.

General psychiatric residents and corrections: moving forensic education beyond the classroom

Mental illness in the criminal justice system is one of the most important and underserved public health challenges in psychiatry today, but few general psychiatry residency programs offer clinical education in correctional psychiatry. Developing such rotations might seem intimidating to educational leaders unfamiliar with the criminal justice system, but a variety of potential solutions exist for residency programs to offer this increasingly important clinical training.

North Carolina resident psychiatrists knowledge of the commitment statutes: do they stray from the legal standard in the hypothetical application of involuntary commitment criteria?

Objectives are to examine North Carolina (NC) resident psychiatrists knowledge of commitment statutes and their willingness to involuntarily admit hypothetical patients who do not meet statutory criteria. It is hypothesized that the need for transportation may be a salient factor. In one vignette the patient had schizophrenia and the other alcohol dependence. The respondents were asked to make a decision about commitment and to rate how 9 specified factors affected their decision. Sixty-one residents responded. Thirty percent answered incorrectly about statutory provisions for 'mental illness' and 'dangerousness', 10% answered incorrectly that grave disability does not meet the dangerousness criterion, and 41% answered incorrectly about the NC statutory language of the 'least restrictive alternative' principle. While neither hypothetical patient met the commitment standard, 74% of respondents would involuntarily admit the patient with psychotic illness and 87% would involuntarily admit the patient with alcohol dependence. Training in commitment standards with clinical vignettes should be conducted with residents to protect patient rights.