Patricia R. Recupero

PTSD Substance abuse comorbidity and treatment utilization

The present study investigates the prevalence of posttraumatic stress disorder (PTSD) among a sample of treatment-seeking substance abusers and examines the relationship between PTSD comorbidity and rates of inpatient substance abuse treatment. Eighty-four patients (48 male and 36 female) admitted for detoxification at a private hospital were administered self-report measures of lifetime stressor events, PTSD symptomatology, and prior treatment history. Approximately one quarter of the sample was found to present with significant PTSD symptomatology. Women were more likely than men to have been physically and sexually abused, and women reported experiencing a greater number of traumatic events. Consequently, more women than men were classified as having possible PTSD. With respect to inpatient substance abuse treatment admission rates, the PTSD group reported a greater number of hospitalizations than their non-PTSD counterparts. Implications of these findings for routine trauma screening and more effective treatment for substance abusers with concomitant PTSD are highlighted.

Adulthood Animal Abuse Among Men Arrested for Domestic Violence

Learning more about intimate partner violence (IPV), perpetrators could aid the development of more effective treatments. The prevalence of adulthood animal abuse (AAA) perpetration and its association with IPV perpetration, antisociality, and alcohol use in 307 men arrested for domestic violence were examined. Forty-one percent (n = 125) of the men committed at least one act of animal abuse since the age of 18, in contrast to the 1.5% prevalence rate reported by men in the general population. Controlling for antisociality and alcohol use, AAA showed a trend toward a significant association with physical and severe psychological IPV perpetration.

Examining the interface between substance misuse and intimate partner violence.

There is considerable theoretical and empirical support for a link between substance misuse and perpetration and victimization of intimate partner violence. This review briefly summarizes this literature and highlights current research that addresses the interface between treatment for substance abuse and intimate partner violence. Suggestions for future research and clinical implications are provided.

Managing risk when considering the use of atypical antipsychotics for elderly patients with dementia-related psychosis.

In 2005, responding to several studies, the FDA issued a black box warning on atypical (second generation) antipsychotic medications, noting that the drugs may increase the risk of cerebrovascular adverse events in elderly patients with dementia-related behavior disturbances. The black box warning has raised concern for clinicians, among whom atypical antipsychotics have gained favor for having a more tolerable side-effect profile than many other pharmacological treatment options. Complicating this concern are studies suggesting that other medications may have similar risks and a dearth of unbiased head-to-head studies comparing different treatment options. To effectively manage risk when treating elderly patients with dementia-related psychosis, physicians, patients, and caregivers must consider both acute risks (such as danger of bodily harm to the patient and others) and long-term risks (such as placement in a restrictive nursing home). If an atypical antipsychotic is chosen, additional risk management may be warranted. This paper presents a brief overview of relevant concerns and suggests some techniques to help minimize and manage risk, such as increased monitoring, informed consent, and thorough documentation. A sample clinical risk management form and a sample letter to the primary care physician are provided to help guide clinicians in improving their risk management practices when working with elderly patients suffering from dementia-related psychosis and related behavioral difficulties.

Sexual harassment in medical education: liability and protection.

The prevalence and frequency of sexual harassment in medical education is well documented. On the graduation questionnaire administered by the Association of American Medical Colleges in 2003, 15% of medical students reported experiences of mistreatment during medical school. On items that specifically address sexual mistreatment, over 2% of students reported experiencing gender-based exclusion from training opportunities, and unwanted sexual advances and offensive sexist comments from school personnel. Sexual harassment of medical trainees by faculty supervisors is obviously unethical and may also be illegal under education discrimination laws. In two cases in 1998 and 1999, the U.S. Supreme Court clarified that schools may be held liable under Title IX of the Education Amendments of 1972 for the sexual harassment of their students. In 2001, the Office of Civil Rights of the Department of Education released revised policy guidelines on sexual harassment that reflect the Supreme Court rulings. Medical school administrators should undertake formal assessments of the educational environment in their training programs as a first step toward addressing the problem of sexual harassment. The authors recommend that medical schools implement measures to both prevent and remedy sexual harassment in their training programs. These constructive approaches include applying faculty and student education, establishing a system for notification and response, and creating an institutional structure to provide continuous evaluation of the educational environment.

Supervisor-trainee relationship boundaries in medical education

Despite concerns about the prevalence and ramifications of medical student mistreatment, the boundaries of faculty-student relationships have not been studied systematically in medical training programs. This study aimed to identify behaviours that occur with some frequency and potentially raise issues related to boundaries in the supervisor-trainee relationship. An anonymous questionnaire was distributed to the mailboxes of 154 residents in the departments of psychiatry, internal medicine, and obstetrics and gynaecology at four hospitals affiliated with Brown University Medical School. Residents were asked to report whether they had encountered specific behaviours from supervisors during medical training, the frequency of these experiences, and the professional status of the supervisor involved in each episode. There was a significant reported incidence of behaviours related to academic/professional boundaries, personal boundaries, and dating boundaries. Some of these behaviours raise issues related to exploitation. The major sources of these reported boundary behaviours were hospital-based clinical faculty, university-based academic faculty, and senior house staff. The potentially adverse effects of boundary behaviours on the individual student, the teacher-student relationship, and the doctor-patient relationship are discussed. Future research is recommended to clarify the limits of appropriate behaviour between supervisors and trainees in the medical learning environment.

Psychiatric Residents’ Experience Conducting Disability Evaluations

ObjectiveThe increasing frequency and societal cost of psychiatric disability underscore the need for accuracy in evaluating patients who seek disability benefits. The authors investigated senior psychiatric residents’ experiences performing disability evaluations, their self-assessment of competence for this task, and whether they perceived a need for more training.MethodsSeventy-nine third- and fourth-year psychiatric residents in Massachusetts and Rhode Island training programs were surveyed from May to June in 2008. Participants were asked about the frequency of requests and completion of disability evaluations, the practice patterns followed when performing evaluations, the identification of role and potential conflict of interest in doing evaluations, and their sense of preparedness and need for more training.ResultsResidents reported having limited experience performing disability evaluations and followed a variety of practice patterns when performing evaluations. They reported having a limited understanding of what constitutes psychiatric disability and a lack of confidence in their ability to perform evaluations accurately. A significant minority had identified patients as disabled despite believing otherwise. A majority of residents reported receiving no didactics on psychiatric disability and desired more training.ConclusionResidents may be unprepared to perform disability evaluations. Residency programs may need to provide additional training.

The Americans with Disabilities Act (ADA) and the Americans with Disabilities Act Amendments Act in Disability Evaluations

Mental health professionals may perform disability evaluations for cases involving the Americans with Disabilities Act (ADA) of 1990. The ADA requires an employee to demonstrate substantial limitation in one or more major life activities in order to invoke the ADA’s protection. The ADA Amendments Act (ADAAA) of 2008 significantly expanded the ADA’s coverage, such that more individuals will meet the statutory requirements to be considered “disabled” under the ADA. Clinicians should have a basic understanding of the recently amended ADA so that they can help patients who may need to invoke the ADA’s protection in order to continue working. Forensic experts may also be asked to assist in ADA cases, as expert witnesses or as consultants, before disputes have escalated to litigation. The mental health professional can help to determine how an employee’s psychiatric impairment (if any) affects occupational functioning, whether the employee poses a direct threat in the workplace, and whether any reasonable accommodations may enable the worker to overcome any functional impairments in performing his or her job. With the enactment of the ADAAA in 2008 and the publication of the Equal Employment Opportunity Commission’s final interpretive rules in 2011, demand for assistance from behavioral health professionals in ADA cases will likely increase in the next several years.

Geïnformeerde toestemming voor e-therapie

E-therapie, psychologische begeleiding of psychotherapie via het internet, levert vele risico’s en voordelen op. Om de aansprakelijkheid te beperken en patienten te beschermen, zouden aanbieders van e-therapie dit duidelijk moeten maken en patienten moeten betrekken in een actieve dialoog. Een grondige procedure van toestemming na voorlichting (informed consent of geinformeerde toestemming) stelt patienten in staat een gefundeerde beslissing te nemen over de vraag of e-therapie voor hun geschikt is. Voordat met de behandeling wordt begonnen, heeft de hulpverlener de plicht relevante risico’s mee te delen, evenals mogelijke voordelen, waarborgen en alternatieven. Kortom: alle informatie die voor een patient relevant zou kunnen zijn om tot een gefundeerde beslissing te komen. De risico’s en voordelen van e-therapie varieren van patient tot patient, en hulpverleners moeten zich afstemmen op de unieke situatie van iedere patient, rekening houdend met factoren als diens specifieke diagnose en symptomen. Andere, nog niet onderkende risico’s rechtvaardigen eveneens een open houding. Dit artikel zal ingaan op de te verstrekken informatie tijdens het toestemmingsproces en zal enkele technieken bespreken om zeker te zijn van het begrip en de toestemming van de patient. Het beoogt de reflectie te bevorderen op de soorten onderwerpen die een hulpverlener te berde zou willen brengen voordat hij met e-therapie begint.

Effectiveness of a Polysubstance Dependence Detoxification Protocol for Patients With Co-occurring Disorders

Patients with polysubstance dependence and co-occurring psychiatric and substance use disorders represent a growing population. This study investigates the safety and effectiveness of a single-scale, symptom-triggered protocol for patients undergoing inpatient detoxification from alcohol, opioids, sedatives, or polysubstance dependence. Medical records staff generated a list of all charts containing a principal discharge diagnosis of alcohol, sedative, opioid, or polysubstance dependence between 2002 and 2004, when the Butler Instrument for Withdrawal Assessment protocol was administered. This list was arranged by terminal digits of the medical record numbers to randomize the selection, and staff pulled the first 100 charts for review. De-identified medical data were recorded from the charts to obtain information about medications, length of stay, and adverse events during hospitalization. The main outcome measures were adverse events and length of stay. The average length of stay was 4.2 days (SD = 2.3), rate of discharge against medical advice was 4% (exactly 4 patients out of 100), and no seizures or delirium tremens were reported. The results of this study suggest that a single-scale, symptom-triggered detoxification protocol can facilitate safe and rapid detoxification and stabilization, even for patients with polysubstance dependence and co-occurring psychiatric and substance use disorders.