Beth Goldman

How Do Clinicians Actually Use the Diagnostic and Statistical Manual of Mental Disorders in Clinical Practice and Why We Need to Know More

Abstract The clinical use of the Diagnostic and Statistical Manual of Mental Disorders (DSM) is explicitly stated as a goal for both the DSM Fourth Edition and DSM Fifth Edition (DSM-5) revisions. Many uses assume a relatively faithful application of the DSM diagnostic definitions. However, studies demonstrate significant discrepancies between clinical psychiatric diagnoses with those made using structured interviews suggesting that clinicians do not systematically apply the diagnostic criteria. The limited information regarding how clinicians actually use the DSM raises important questions: a) How can the clinical use be improved without first having a baseline assessment? b) How can potentially significant shifts in practice patterns based on wording changes be assessed without knowing the extent to which the criteria are used as written? Given the American Psychiatric Association’s plans for interim revisions to the DSM-5, the value of a detailed exploration of its actual use in clinical practice remains a significant ongoing concern and deserves further study including a number of survey and in vivo studies.

Psychiatrists' Attitudes Toward Individuals With Substance Use Disorders and Serious Mental Illness

Objective: The attitudes of psychiatrists toward individuals with highly stigmatized conditions such as substance use disorders and serious mental illness may influence treatment effectiveness. These attitudes may be influenced by factors including previous specialty training and current practice patterns. This study examined the attitudes of addiction and community psychiatrists toward individuals with diagnosed schizophrenia, polysubstance dependence, comorbid schizophrenia and polysubstance dependence, and depression. Methods: A web-based survey link was sent to the electronic mailing lists of addiction and community psychiatry associations. Results: A total of 84 respondents identified themselves as either addiction (n = 54) or community (n = 30) psychiatrists. The majority were male (70% of addiction and 57% of community psychiatrists) with an average age of 56.0 (SD = 11.86) and 52.7 (SD = 11.8), respectively. Addiction psychiatrists had less stigmatizing attitudes than community psychiatrists for individuals with polysubstance dependence (p < .0001), while community psychiatrists had less stigmatizing attitudes than addiction psychiatrists for those with schizophrenia (p < .0001). Attitudes toward individuals with dual diagnosis did not vary significantly by psychiatrist group, but both addiction and community psychiatrists had more stigmatizing attitudes for individuals with dual diagnosis (p < .0001). Conclusions: These findings suggest that even psychiatrists working with highly stigmatized groups of individuals may continue to hold stigmatizing attitudes toward people with other diseases. Future work is needed to further assess stigmatizing attitudes among psychiatrists and the impact of these attitudes on quality of care, as well as interventions such as specialized education and training to reduce such stigma among psychiatrists.

The Psychiatric Note in the Era of Electronic Communication

The electronic medical record (EMR) is a central component of health care reform and is already implemented in many settings (Blumenthal, 2009). Some clinicians may find this a desirable and others an undesirable development (Baron, 2007; Garg et al., 2005; Mangalmurti et al., 2010; Sittig and Classen, 2010); however, increasing numbers of mental health clinicians now face the challenge of using the EMR wisely and therapeutically in settings in which such systems are now, or soon will be, operative (Mojtabai, 2007). This article illustrates how the EMR can be used to benefit patients and providers while understanding that as with all change there are potential anticipated and unanticipated problems. In most ways, the psychiatric note in the EMR is not radically different from traditional notes in paper medical records. The EMR note continues to address the tasks of documenting the psychiatric assessment, current treatment regimens, outcomes, and future treatment steps. However, the legibility and accessibility of EMR notes greatly increase the degree of “sharedness” of treatment assessment and planning with cotreaters and patients. The increased degree of “sharedness” of the EMR can foster treatment continuity and effective communication between a team of providers. To reap these benefits, the EMR requires us to produce clear, comprehensive but relatively brief notes. Although clear concise notes were desirable in the paper-based medical record, the EMR makes such notes essential. The EMR will be more readily available to the patients and other clinicians, potentially posing issues for the patient clinician alliance but also potentially increasing the opportunities for greater clinician-patient collaboration. While the paper charts were always “permanent,” the new accessibility of an EMR results in notes that are also more easily retrieved. This raises concerns regarding potentially “sensitive” information discussed during mental health treatment. We illustrate the potential benefits and clinical concerns using 2 clinical vignettes in 2 different treatment settings. Dr. A and Dr. H work in settings in which the EMR is being introduced. Dr. A works in a tertiary care academic medical center and treats Mr. J for depression and narcissistic personality disorder with combined medication and psychotherapy. An EMR would make the diagnosis of narcissistic personality disorder more transparent and result in a discussion between Dr. A and his patient that may enhance or threaten their working alliance. Dr. H works at the local community mental health center and treats Mr. B for schizophrenia. Mr. B has ongoing delusions regarding a computer chip in his head, and may react poorly to the news that his notes are now available in electronic format.

Rational Protection of Subjects in Research and Quality Improvement Activities

This Open Forum illuminates shortcomings with the basis for determining degree of oversight of health services research and quality improvement activities. Using a federally regulated definition of research rather than a direct appraisal of risk to patients can misallocate effort from activities with higher risk for patients to those with lower risk. The case of the Johns Hopkins multicenter study of central line safety checklists in intensive care units is cited. Definitions of research promulgated by the Office of Human Research Protection are reviewed, and an alternative model based on patient risk is proposed. Suggestions for how quality improvement work fits into the larger paradigm of research are made.

Our job and their jobs: mental health clinicians and patients' work functioning.

The capacity to love and work is a timeless definition of a mentally healthy individual. Conservatively 23 million working-age Americans have chronic health and mental health problems that diminish their ability to work (Hoffman and Rice, 1996). Millions more are projected to experience employment problems by 2030 (Lerner et al., 2005). There is a reciprocal relationship between illness and work, with symptoms impairing functioning and poor functioning worsening recovery. Mental health clinicians have long recognized the importance of work in their patients’ lives and know how to assess and manage symptom reduction and interpersonal functioning. However, they may feel less confident in their ability to assess work functioning beyond basic issues of employment status. Moreover, clinicians may ignore employment aspirations and job performance because of an assumption that function will improve as symptoms improve (Lerner and Henke, 2008). An evolving literature has documented the degree to which mental health conditions impair work functioning and has indicated that symptom reduction alone does not improve job performance and satisfaction (Adler et al., 2006; Bacharach et al., 2010; Blum et al., 1993; Greenberg et al., 2003; Kessler et al., 2001; Lerner et al., 2004b; Stewart et al., 2003). Using the example of depressive disorders, this article will provide a case presentation and offer a framework for understanding the impact of mental health conditions on work performance. We present a methodology for systematic assessment and treatment of work functioning as part of routine patient care. Improving work performance should be a principle goal of treatment. Depression affects almost 5% of the US working-age population (Berndt et al., 1998; Broadhead et al., 1990; Goetzel et al., 2003; Kessler et al., 1999a), and like several other mental disorders, it has been found to be associated with job loss, job turnover, absenteeism, and reduced job performance (now known as presenteeism; Adler et al., 2006; Budetti et al., 2000; Dooley et al., 1996; Greenberg et al., 2003; Kessler et al., 2001; Lerner et al., 2004a, 2004b, 2010; Stewart et al., 2003) at an estimated productivity cost of

Why We Need to Enhance Suicide Postvention: Evaluating a Survey of Psychiatrists’ Behaviors after the Suicide of a Patient

44 billion annually (Greenberg et al., 2003). Studies reveal that depressed workers miss an average of 0.5 to 4.0 workdays per month (Kessler et al., 1999a). Poor work performance may be an even larger problem. Stewart et al. (2003) suggest that it is more costly than medical care, absences, and disability combined. Conti and Burton (1995) found that depressed workers were impaired on the job approximately 35% of the time on average in a 2-week period. Despite the availability of effective pharmacological and therapeutic interventions, optimal care has been hindered by underdiagnosis, limited use of evidence-based approaches, and adherence problems (Calkins et al., 1991; Eisenberg, 1992; Kessler et al., 1996; Schulberg et al., 1995). In essence, depression causes a partial work disability. A second critical observation has been the low correlation between symptom response to treatment and functional improvement. Adler et al. (2006) found that compared with healthy controls, a recovered group of previously depressed employees had persistently lower ability to function on the job. Depression symptom severity explains part of the variation in work outcomes. Depression treatment studies indicate that guideline-concordant care may only partially prevent depression’s negative impact on work. A study of depression treatment and employment achieved a reduction in depressive symptoms and absenteeism but not improved job performance (Wang et al., 2007). COMMENTARY

Implementing Standardized Assessments in Clinical Care: Now's the Time

Abstract Suicide prevention efforts are increasing to enhance capabilities and better understand risk factors and etiologies. Postvention, or how clinicians manage the postsuicide aftermath, strengthens suicide prevention, destigmatizes the tragedy, operationalizes the confusing aftermath, and promotes caregiver recovery. However, studies regarding its efficacy are minimal. The Psychopathology Committee of the Group for the Advancement for Psychiatry surveyed a convenience sample of psychiatrists to better understand postvention activities. Ninety psychiatrists completed the survey; they were predominantly men (72%) with an average of 24.6 years of experience (SD, 16.7 years). Most had contact with the patients family within 6 months of the suicide, and most psychiatrists sought some form of support. Few psychiatrists used a suicide postvention procedure or toolkit (9%). No psychiatrists stopped clinical practice after a patient suicide, although 10% stopped accepting patients they deemed at risk of suicide. Postvention efforts, therefore, should be improved to better address survivor care.