Structural Racism and Psychiatric Practice: A Call for Sustained Change.

ABSTRACT: Structural racism has received renewed focus over the past year, fueled by the convergence of major political and social events. Psychiatry as a field has been forced to confront a legacy of systemic inequities. Here, we use examples from our clinical and supervisory work to highlight the urgent need to integrate techniques addressing racial identity and racism into psychiatric practice and teaching. This urgency is underlined by extensive evidence of psychiatry's long-standing systemic inequities. We argue that our field suffers not from a lack of available techniques, but rather a lack of sustained commitment to understand and integrate those techniques into our work; indeed, there are multiple published examples of strategies to address racism and racial identity in psychiatric clinical practice. We conclude with recommendations geared toward more firmly institutionalizing a focus on racism and racial identity in psychiatry, and suggest applications of existing techniques to our initial clinical examples.

Psychiatry in the Time of COVID: Credibility, Uncertainty, and Self-Reflection.

ABSTRACT: Public trust in the credibility of medicine and physicians has been severely tested amid the COVID-19 pandemic and growing sociopolitical fissures in the United States. Physicians are being asked to be ambassadors to the public of scientific information. Psychiatrists have an opportunity to help the public understand and accept a "new normal" during a time of such uncertainty. Using a case example, we review the impact of uncertainty and fear on scientific and medical credibility. Although the pandemic provides an opportunity for systemic change, the consequences of any change remain unknown. To help patients navigate the uncertainty, we conclude by offering four guidelines to clinicians: the public has little interest in understanding the scientific method; we need to acknowledge that we do not have all the answers; credibility and trustworthiness are linked to our ability to be trusted, believable messengers; and we can retain scientific credibility while acknowledging uncertainty.

Telehealth and the Community SMI Population: Reflections on the Disrupter Experience of COVID-19.

The novel coronavirus pandemic and the resulting expanded use of telemedicine have temporarily transformed community-based care for individuals with serious mental illness (SMI), challenging traditional treatment paradigms. We review the rapid regulatory and practice shifts that facilitated broad use of telemedicine, the literature on the use of telehealth and telemedicine for individuals with SMI supporting the feasibility/acceptability of mobile interventions, and the more limited evidence-based telemedicine practices for this population. We provide anecdotal reflections on the opportunities and challenges for telemedicine drawn from our daily experiences providing services and overseeing systems for this population during the pandemic. We conclude by proposing that a continued, more prominent role for telemedicine in the care of individuals with SMI be sustained in the post-coronavirus landscape, offering future directions for policy, technical assistance, training, and research to bring about this change.

Managing Our Public Selves.

The Internet has fundamentally altered mental health clinicians' "public selves," challenging previous models of self-disclosure and maintenance of boundaries within treatment. The conception of a public self altered by the digital age presents both opportunities and pitfalls in clinical practice. Information about clinicians available online may be professional or personal; accurate or inaccurate; and publicly accessible, purchased, or hacked. Clinicians must consider how to manage their public selves in work with patients and the community. This Open Forum outlines a set of recommendations for managing the public self in the digital age as a routine part of therapeutic work.

The Opioid Epidemic and Psychiatry: The Time for Action Is Now.

The number of people with opioid use disorder and the number of overdose deaths in the United States have increased dramatically over the past 20 years. U.S. Congress passed the SUPPORT for Patients and Communities Act, which was signed into law in 2018, authorizing almost $8 billion to address the crisis. As experts in the treatment of central nervous systems disorders, psychiatrists can play a leading role in expanding treatment for people with opioid use disorder and in advocating for policy changes to support community treatment for this group.

How the DSM Is Used in Clinical Practice.

Despite widespread use, how clinicians use the DSM in psychiatric practice is not well understood. Recognizing public and professional attitudes toward the DSM are integral to future DSM development, to assess a commonly held assumption such as that the DSM is used primarily for coding, and to assess its clinical utility. A convenience sample of Psychiatric Times readers was surveyed to assess the DSM's use in clinical practice. A total of 394 behavioral health care practitioners fully completed the online survey. Results suggest that the DSM, beyond administrative and billing use, is used for communication with health care providers, for teaching diagnoses to trainees, and, importantly, as an educational tool to inform patients and caregivers alike.

Adaptation in Delivering Integrated Care: The Tension Between Care and Evidence-Based Practice.

Clinical practice is assumed to be informed and supported by evidence-based clinical research. Nonetheless, clinical practice often deviates from the research evidence base, sometimes leading and sometimes lagging. Two examples from integrated care in mental health care (care for serious mental illness and collaborative mental health care in primary care settings) illustrate the natural space and therefore tension between evidence and implementation that needs to be better understood. Using the tools and perspectives of both examples, the authors present a framework for the connected relationship between practice and research that is founded on measurement and uses iterative adaptation guided by oversight of and feedback from the stakeholders in this process.

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

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 patient's 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.

How do clinicians actually use the Diagnostic and Statistical Manual of Mental Disorders in clinical practice and why we need to know more.

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.

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.

Implementing standardized assessments in clinical care: now's the time.

In this Open Forum the Committee on Psychopathology within the Group for the Advancement of Psychiatry (GAP) strongly encourages clinicians and health systems to implement standardized assessments of patients' outcomes for mental disorders, particularly disorders such as depression. The GAP committee describes how calls for the regular use of standardized scales in clinical settings naturally follow from the development and dissemination of treatment guidelines. It discusses the challenges involved in implementing routine outcome measures in clinical settings and explains why the advantages of measurement-based care make addressing these challenges worthwhile. Finally, the committee makes practical suggestions for clinicians and systems attempting to implement routine outcome measures in their clinics.

Psychiatrists and primary caring: what are our boundaries of responsibility?

This column provides a framework for considering the extent of psychiatrists' responsibility for patients' medical conditions. Psychiatrists have the greatest responsibility for medical conditions that occur as a result of their own actions. Next on the continuum of responsibility is psychiatrists' obligation to remain alert for medical conditions that can cause, trigger, or exacerbate psychiatric conditions or interfere with treatment. Another potential responsibility is for preventive monitoring, screening, and education for medical conditions that disproportionately affect psychiatric patients. Characteristics of the setting, practitioner, and patient that affect how such responsibilities are fulfilled are also discussed.

Translating research into practice: are physicians following evidence-based guidelines in the treatment of hypertension?

Despite the widespread availability of evidence-based guidelines for treating hypertension, recent evidence suggests that physicians may not be prescribing first-line drugs for their patients with high blood pressure. Using administrative claims data from 1998 through 2000, this study investigates whether drug treatment provided to 6,736 hypertensives in a privately insured, non-HMO population follows practice guidelines. The authors also examine physician and patient-related factors associated with guideline adherence in a subset of patients with newly diagnosed hypertension. Among members with high blood pressure alone, only 38 percent were on a diuretic, while less than a third were prescribed a beta-blocker, the JNC VI recommended first-line antihypertensives for essential hypertension. Approximately half of individuals with high blood pressure and certain comorbidities received non-first-line interventions. Such findings indicate the need to reconsider how guidelines are communicated and shared with medical practitioners and patients, particularly in light of the drug industry's promotion of newer, more expensive drugs.