Legal and Ethical Challenges in Emergency Psychiatry, Part 2: Management of Inmates

Psychiatrists and clinicians encounter unique situations, challenges, and requirements in the treatment of jail and prison inmates in the emergency department. This article reviews the historical legal highlights pertaining to medical and psychiatric care of inpatients, as well as the professional, ethical, and legal aspects that allow clinicians to evaluate, treat, and properly disposition their inmate patients. In particular, this article discusses the specific suicide risk factors related to inmates and correctional facilities that should be ascertained and managed in a clinician's suicide risk assessment and intervention planning in this special high suicide risk patient population.

Legal and Ethical Challenges, Part 1: General Population

Several federal and state laws and regulations, as well as ethical medical principles, govern the emergency clinician's practice of care. Although some common legal-medical and ethical principles are shared with other medical specialties, emergency medicine and emergency psychiatry have unique legal and ethical challenges. This article presents and discusses these challenges, including the physician-patient relationship, malpractice, confidentiality and privilege, duty to report, decision-making capacity and vicarious decision-making, the Emergency Medical Treatment and Labor Act, right to treatment, hospital admissions, involuntary commitment, forced medication administration, and child and elder abuse.

Preventing Alcohol and Tobacco Exposed Pregnancies: CHOICES Plus in Primary Care

INTRODUCTION

Alcohol and tobacco use are common among U.S. women, yet if used during pregnancy these substances present significant preventable risks to prenatal and perinatal health. Because use of alcohol and tobacco often continue into the first trimester and beyond, especially among women with unintended pregnancies, effective evidence-based approaches are needed to decrease these risk behaviors. This study was designed to test the efficacy of CHOICES Plus, a preconception intervention for reducing the risk of alcohol- and tobacco-exposed pregnancies (AEPs and TEPs).

STUDY DESIGN

RCT with two intervention groups: CHOICES Plus (n=131) versus Brief Advice (n=130). Data collected April 2011 to October 2013. Data analysis finalized February 2016.

SETTING/PARTICIPANTS

Settings were 12 primary care clinics in a large Texas public healthcare system. Participants were women who were non-sterile, non-pregnant, aged 18-44 years, drinking more than three drinks per day or more than seven drinks per week, sexually active, and not using effective contraception (N=261). Forty-five percent were smokers.

INTERVENTION

Interventions were two CHOICES Plus sessions and a contraceptive visit or Brief Advice and referral to community resources.

MAIN OUTCOME MEASURES

Primary outcomes were reduced risk of AEP and TEP through 9-month follow-up.

RESULTS

In intention-to-treat analyses across 9 months, the CHOICES Plus group was more likely than the Brief Advice group to reduce risk of AEP with an incidence rate ratio of 0.620 (95% CI=0.511, 0.757) and absolute risk reduction of -0.233 (95% CI=-0.239, -0.226). CHOICES Plus group members at risk for both exposures were more likely to reduce TEP risk (incidence rate ratio, 0.597; 95% CI=0.424, 0.840 and absolute risk reduction, -0.233; 95% CI=-0.019, -0.521).

CONCLUSIONS

CHOICES Plus significantly reduced AEP and TEP risk. Addressing these commonly co-occurring risk factors in a single preconception program proved both feasible and efficacious in a low-income primary care population. Intervening with women before they become pregnant could shift the focus in clinical practice from treatment of substance-exposed pregnancies to prevention of a costly public health concern.

TRIAL REGISTRATION

This study is registered at clinicaltrials.gov NCT01032772.

The Prevalence of Physicians Who Have Been Stalked: A Systematic Review

It has been suggested that physicians are particularly vulnerable to being stalked. Our goal was to examine the prevalence of physicians who have been stalked and the associated consequences for the victims. We conducted multiple searches of PubMed and PsycINFO for articles in English from 1950 to 2013, using the terms stalker, stalking, aggression, assaults, patient, physician, resident, registrar, intern, and trainee. Reference lists of relevant articles were also searched. We developed and used a five-point evaluation tool for critical appraisal of the articles. We found 12 prevalence studies on the stalking of physicians, of which 8 were national surveys and 4 were focused exclusively on stalking. The studies varied in their methodological quality with common limitations including the lack of a national sample, the lack of construct validity of the survey tool and of the provision of a formal definition of stalking, and low response rates. Prevalence rates ranged from 2 to 25 percent, although one study found a prevalence rate of 68.5 percent. Information on the physical and psychological consequences of having been stalked was also limited. Although a substantial minority of physicians reported having been stalked, there remains a dearth of high-quality studies on the topic.

Utilization of psychiatric services by postpartum women in a predominantly minority, low-socioeconomic-status, urban population

This study describes the utilization of health care services related to psychiatric diagnoses in an inner city community health organization with a largely Hispanic population of low socioeconomic status. We reviewed the frequency and timing of postpartum mental health diagnoses among 5,731 patients who delivered babies and were followed-up for postpartum care. 286 women (5 %) had at least one mental health diagnosis. The rates in white, black, and Hispanic women were 12, 8, and 5 % respectively (p < .05). White and black women were 2.5 (95 % CI 1.24, 5.07), and 1.62 (95 % CI 1.09, 2.40) times more likely to have a mental health diagnosis, respectively, compared to Hispanic women. The most common diagnoses were mood disorders (64 %) followed by anxiety disorders (29 %). 87 % of cases were diagnosed after 4 weeks postpartum. The postpartum mental health diagnosis rate seen here is lower than might be expected, particularly among Hispanic women. Possible explanations are discussed.

Prevalence and treatment of frotteurism in the community: a systematic review

This article describes a systematic review of prevalence studies on frotteurism. We searched the following databases for previously published, peer-reviewed studies that used suitable diagnostic methods in adult nonclinical samples: Ovid MEDLINE, PsycINFO, Pubmed, AccessMedicine, Cochrane Library, Books@Ovid, DynaMed, Micromedex, Science Direct, and SciVerse Scopus. We conducted multiple searches using the following terms: frotteu*, frottage, frotteurism, paraphilia, paraphilic, courtship disorder, prevalence, treatment, diagnosis, and chikan, and we evaluated the articles by using a six-point epidemiologic quality tool. We identified four prevalence studies, all of which were of limited methodological quality. Limitations included small sample sizes, the use of local rather than national samples, the failure to apply DSM or ICD-9 diagnostic criteria, and the lack of assessment regarding the reliability of diagnostic tools. One small study, a statistical outlier, reported a prevalence of 35 percent. In the three other studies, the prevalence of frotteurism was 7.9 percent, 9.1 percent, and 9.7 percent. We found no studies addressing treatment that met our inclusion criteria. Our findings reveal a need to develop more rigorous research on this topic.

Evaluating patient adherence to antidepressant therapy among uninsured working adults diagnosed with major depression: results of the Texas Demonstration to Maintain Independence and Employment study

This study examined antidepressant adherence and persistence among uninsured working adults diagnosed with major depression enrolled in the Texas Demonstration to Maintain Independence and Employment (DMIE) program. Antidepressant adherence was measured between intervention and control cohorts using proportion of days covered (PDC) during a 365-day observation period. Persistence examined duration of time from drug initiation to discontinuation based on a ≥35-day refill supply gap. Older, non-minority patients with higher education were more adherent or persistent to antidepressant therapy. Adjusting for covariates, results showed no significant difference in PDC at the end of 12-months between intervention and control participants (b = .07, P = .054, semi-partial η (2) = .02). Exploratory analysis found subgroup differences in PDC among the study recruitment cohorts. No significant difference between intervention and control groups was found in persistence between the groups. Follow-up investigation is planned to assess the longer term impact of the DMIE program on antidepressant adherence and persistence.

A systematic review of the prevalence of patient assaults against residents

OBJECTIVES

The purpose of this study is to systematically review the literature on the prevalence of patient assaults against residents in all specialties, and to identify curricula that address this issue.

METHODS

The authors searched published English-language literature using PubMed and Scopus databases using key terms including "patient," "assaults," "threats," "violence," "aggression," and "residents." A separate search to identify curricula used the same terms in combination with key words including "curriculum," "didactics," and "course." Bibliographies of studies found by electronic searches were also searched manually.

RESULTS

Fifteen studies met the inclusion criteria. Of these, 7 were conducted on psychiatry residents alone, 6 assessed assaults on residents in nonpsychiatric specialties, and 2 reported cross-specialty data. The prevalence of assaults was defined as the percentage of residents who have experienced at least one assault. The prevalence of physical assaults on residents was 38% in surgery, 26% in emergency medicine, 16% to 40% in internal medicine, 5% to 9% in pediatrics, and 25% to 64% in psychiatry. All studies were cross-sectional; none collected data prospectively. Definitions of assault were heterogeneous or not specified. Few of the assaults were reported to clinical supervisors or training directors, and no programs had a formal reporting process. Approximately 21% to 79% of psychiatry residents and 30% of residents in other specialties had received some training on how to manage violent patients. We found no descriptions of formal curricula for managing the possibility of patient violence against residents or for preparing for the aftermath.

CONCLUSIONS

Although the data are limited, assaults by patients are commonly experienced by residents in training. There is a paucity of information and curricula that pertain to reducing the prevalence of these incidents and to addressing potential psychologic consequences, especially in nonpsychiatric specialties.

Ketamine for treatment-resistant unipolar depression: current evidence

Currently available drugs for unipolar major depressive disorder (MDD), which target monoaminergic systems, have a delayed onset of action and significant limitations in efficacy. Antidepressants with primary pharmacological targets outside the monoamine system may offer the potential for more rapid activity with improved therapeutic benefit. The glutamate system has been scrutinized as a target for antidepressant drug discovery. The purpose of this article is to review emerging literature on the potential rapid-onset antidepressant properties of the glutamate NMDA receptor antagonist ketamine, an established anaesthetic agent. The pharmacology of ketamine and its enantiomer S-ketamine is reviewed, followed by examples of its clinical application in chronic, refractory pain conditions, which are commonly co-morbid with depression. The first generation of studies in patients with treatment-resistant depression (TRD) reported the safety and acute efficacy of a single subanaesthetic dose (0.5 mg/kg) of intravenous ketamine. A second generation of ketamine studies is focused on testing alternate routes of drug delivery, identifying methods to prevent relapse following resolution of depressive symptoms and understanding the neural basis for the putative antidepressant actions of ketamine. In addition to traditional depression rating endpoints, ongoing research is examining the impact of ketamine on neurocognition. Although the first clinical report in MDD was published in 2000, there is a paucity of adequately controlled double-blind trials, and limited clinical experience outside of research settings. Given the potential risks of ketamine, safety considerations will ultimately determine whether this old drug is successfully repositioned as a new therapy for TRD.

Integrating behavioral health and primary care: the Harris County Community Behavioral Health Program

This column describes and evaluates the Harris County Community Behavioral Health Program, a new integrated care program operating in community health centers serving low-income uninsured residents in Houston, Texas. Patient service data, provider satisfaction, patient outcome data, and appointment waiting periods were obtained to evaluate the initial operation of the program. The integrated care program has been successfully implemented on a large scale at an annual cost of about dollars 800,000, or dollars 268 per patient served. About 3,000 patients were treated for behavioral problems by behavioral health staff during the first 11 months of the program. In addition, efforts were made to expand the scope of behavioral health interventions provided by primary care physicians. Providers were satisfied with the program, improvement was detected among patients treated, and there was an increase in the average number of community-based behavioral health services received per patient since the program was implemented.