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The Management of Depression during Pregnancy: A Report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists
Objective—To address the maternal and neonatal risks of both depression and antidepressant exposure and develop algorithms for periconceptional and antenatal management. Method—Representatives from the American Psychiatric Association, the American College of Obstetricians and Gynecologists and a consulting developmental pediatrician collaborated to review English language articles on fetal and neonatal outcomes associated with depression and antidepressant treatment during childbearing. Articles were obtained from Medline searches and bibliographies. Search keywords included pregnancy, pregnancy complications, pregnancy outcomes, depressive disorder, depressive disorder/dt, abnormalities/drug-induced/epidemiology, abnormalities/drug-induced/et. Iterative draft manuscripts were reviewed until consensus was achieved.
Resource Document on Access to Firearms by People with Mental Illness Approved by the Joint Reference Committee, June 2009 Reports of mass shootings and other serious firearmrelated violence, such as the Columbine shootings of 1999 and the Virginia Tech shootings in 2007, are often accompanied by indications that the perpetrator had some emotional disturbance or mental illness. These incidents have raised growing concern about access to firearms (1) by people with mental disorders. Current federal law (2) and the laws of several states (3) bar purchase of firearms by specified categories of people, including persons with certain mental health histories, particularly involuntary hospitalization. These statutes aim to prevent sale of firearms to ineligible persons by requiring dealers to confirm the person’s eligi-bility by running a “check” through the National Instant Criminal Background Check System (NICS). However, as became evident in the wake of the Virginia Tech shootings, most states do not now report information on mental health histories to the NICS. By enacting the NICS Improvement Act of 2007 (4), Congress sought to encourage the states to establish registries of persons who have had the mental health histories that make them ineligible to purchase firearms under federal law.
Complementary and Alternative Medicine (CAM) is a term used to represent a number of specific treatments with potentially high public health importance and benefits. That which constitutes conventional or mainstream medicine is subjective and evolves over time. “Complementary” refers to approaches that are not considered mainstream or conventional, but are consistent with Western concepts based on the biomedical model. “Alternative” approaches are usually considered outside of the traditional Western medical conceptual framework. “Integrative” medicine refers to the combination of CAM and conventional treatments with the goal of achieving the best clinical outcomes for patients. CAM has also been defined as “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine” (NCCAM, 2002).
Guidelines for psychiatrists in consultative, supervisory or collaborative relationships with nonphysician clinicians
The practice of psychiatry and of other mental health disciplines frequently occurs in the framework of organized health delivery systems. Psychiatrists are working with other professionals and nonprofessionals in hospital settings, community mental health centers, health maintenance organizations, as well as in group practices, and in consultative work with schools, family agencies, court clinics, etc. Interprofessional relationships are an essential aspect of good patient care and should be encouraged. They serve as a valuable educational experience and contribute to the continuing development of all who are concerned with patient care. The addition of other professionals and extenders to the health team enlarges the capacity to provide service. In turn, this requires a review of the role and responsibilities of psychiatrists in the entire range of consultative, supervisory, and collaborative relationships.
Vagal nerve stimulation for treatment resistant epilepsy has been available in the United States since 1997, and improved mood noted in epilepsy patients led to studies examining the use of VNS for treatment resistant depression. VNS implantation consists of placement of the stimulator in the chest wall that is attached by wires tunneled through the skin to the left vagus nerve in the carotid sheath. Potential side effects include voice alteration, hoarseness, coughing, paresthesia, dyspnea and rarely vocal cord paralysis and infection1.
Abortion is a fact in the lives of many women. Approximately 20% of American women of childbearing age have already had an abortion, and it is estimated that one out of three American women will have had one by age 45.1 Robinson and colleagues authored a review article entitled “Is there an abortion trauma syndrome? Critiquing the evidence?” (2008)2 that exemplifies the American Psychiatric Association’s position on reproductive rights. Accordingly, the content of this Position Statement is largely based on that article and its cited references. There has been much debate
Advance directives were developed in the context of end of life care and are generally associated with medical and surgical decision-making for permanently incapacitated patients. Within psychiatry, interest in advance directives has been expressed as a means of facilitating the treatment of individuals afflicted with serious mental illnesses (Appelbaum, 1979). These disorders are typified by recurrent episodes of severe, cognition-impairing symptomatology that often result in decisional incapacity. Psychiatric advance directives (PADs) hold the promise of allowing individuals with mental illness, during a time of stability, to record treatment preferences that will presumptively guide the direction of care during incapacitating periods of illness.
Elderly persons often have complex medical and psychiatric needs for which the input of different medical specialties and clinical disciplines is required. The involvement of multiple specialists gives patients access to greater expertise than any single clinician could provide; however, it presents significant challenges of coordination and integration of health care. We endorse the ideal of providing wellcoordinated interdiscipli-nary treatment to older Americans with psychiatric and medical problems but recognize that this ideal is not easily or often fully realized. In this document, we provide a brief review of the problem and describe a number of models that seek to provide exemplary care to elderly persons with psychiatric and medical problems by mobilizing and integrating the input of multiple specialties and clinical disciplines. We conclude with recommendations for policy, services design, and training.
A psychiatrist’s death or incapacity raises immediate problems in the areas of clinical coverage, administrative responsibilities, and medical records. The time to plan for this situation is, of course before such an emergency occurs. By developing the attached guide, the APA is responding to the members’ needs by offering a member benefit that extends to the psychiatrist’s family and colleagues. This document was written to provide relevant and practical guidance to both the psychiatrist and his/her colleagues and family.
Psychiatrists should maintain respect for their patients' commitments (values, beliefs and worldviews). a. It is useful for clinicians to obtain information on the religious/spiritual commitments of their patients so that they may properly attend to them in the course of assessment, formulation, and treatment. b. Empathy for the patient's sensibilities and particular commitments is essential. Conflicts, either within the patient or within the clinician-patient relationship should be handled with a concern for the patient's vulnerability to the attitudes of the psychiatrist. c. Interpretations that concern a patient's commitments should be made with empathic respect for their meaning and importance to the patient.
This resource document discusses the use of seclusion or restraint for purposes of mental health intervention in jails and prisons, in contrast to its use for correctional purposes (i.e., specifically custody reasons).** The use of seclusion or restraint for mental health reasons is an emergency measure to prevent imminent harm to the patient or other persons when other means of control are not effective or appropriate.
Psychiatrists' responses to requests for psychiatric information in federal personnel investigations
Psychiatrists routinely receive and respond to patient authorizations to release information to third parties. However, a security clearance-related request for information differs from an ordinary release of information generally encountered in clinical practice. An ordinary release specifies records, notes, admission or discharge summaries, or other information generated in the course of clinical care. Most often, the information is to be released to another provider or facility for use in a therapeutic context, for the benefit of the individual patient. In contrast, the security clearancerelease may call for the psychiatrist to make a judgment about his or her patient (i.e., does the patient have a condition that could impair judgment or reliability in the context of safeguarding national security information, or be at risk for future violent behavior) that could be disqualifying for employment. Although this resource document deals only with requests for psychiatrists' disclosures with regard to security clearances, the similarities to other work-related evaluations (e.g., can the individual return to work, can the individual function as a police officer), or to other circumstances in which disclosures may be used for legal or administrative purposes (e.g., forensic evaluations) should be noted.