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Managing schizophrenia as a chronic disease linked to better outcomes
TAMPA – The secret to optimal long-term disease control in schizophrenia is to implement the same type of continuous and close management provided to other chronic diseases, like hypertension or inflammatory bowel disease, according to a lecture delivered at the annual meeting of the American College of Psychiatrists.
In the Dean Award Lecture – a talk characterized as “a stroll through the long-term understanding of the treatment of schizophrenia” – Ira D. Glick, MD, said that, although antipsychotics provide the foundation of disease control, patients and families need to understand and respect disease chronicity.
“In the last 5 or 6 years, I did something that no one has ever done before. I looked at the outcomes of patients treated for decades,” Dr. Glick recounted. Specifically, he contacted patients who had been in his care for up to 50 years. In “this naturalistic study,” he specifically asked the patients to rate their adherence to antipsychotics and to provide a global assessment of their life satisfaction, both on a scale of 1-10.
“What I found in a relatively large sample was that the more adherent patients were to their medication, the more likely they were to report adequate satisfaction with their life,” Dr. Glick said. For those who were not adherent, life in general “has been a disaster.”
This finding is not entirely surprising given the power of antipsychotics to change thinking. However, for those engaged in the immediate task of controlling acute symptoms, the importance of chronicity might not be given adequate emphasis. This requires educating patients and their families about the need to embark on lifetime treatment, Dr. Glick said. Like a diagnosis of diabetes, a diagnosis of schizophrenia means constant vigilance for manifestations of disease and appropriate adjustments of therapy to improve long-term outcomes.
Since evaluating the relationship between medication adherence and long-term outcomes in patients with schizophrenia treated at Stanford, the same type of evaluation was conducted with population samples from the Veterans Affairs system and from China. The data “show exactly the same thing,” Dr. Glick said.
It is important to use every available resource in helping patients recognize and deal with schizophrenia chronicity.
Earlier in his career, Dr. Glick participated in a randomized clinical trial of hospitalization for patients with schizophrenia. Recounting that experience, he reported that he was struck by the improvement in outcomes among patients who grasped that schizophrenia must be approached as a chronic disease.
“Once the patient understood what they had, they were much more apt to be adherent and to stay on their medication for their lifetime,” Dr. Glick reported. Although there is evidence that identifying an effective antipsychotic is key to disease control, “you have to talk to the patient, not just throw a medicine at them,” he said. This makes educating patients and families the key step in embarking on indefinite, close disease monitoring.
Control of schizophrenia over time is likely to vary as symptoms wax and wane, but this is true of other chronic disease processes. Diabetes, for example, requires frequent monitoring for and adjustment of blood glucose. Often medications for diabetes must be intensified or switched. The monitoring and management of schizophrenia is analogous.
One strategy for improving control of schizophrenia is to educate patients about this concept. Approaching schizophrenia as a chronic illness like other diseases that require lifetime drugs will help reduce the crises and the adverse effects associated with nonadherence to tight management, Dr. Glick maintained.
Dr. Glick reported financial relationships with Forum Pharmaceuticals, Johnson & Johnson, Neurocrine, Sunovion, and Teva.
TAMPA – The secret to optimal long-term disease control in schizophrenia is to implement the same type of continuous and close management provided to other chronic diseases, like hypertension or inflammatory bowel disease, according to a lecture delivered at the annual meeting of the American College of Psychiatrists.
In the Dean Award Lecture – a talk characterized as “a stroll through the long-term understanding of the treatment of schizophrenia” – Ira D. Glick, MD, said that, although antipsychotics provide the foundation of disease control, patients and families need to understand and respect disease chronicity.
“In the last 5 or 6 years, I did something that no one has ever done before. I looked at the outcomes of patients treated for decades,” Dr. Glick recounted. Specifically, he contacted patients who had been in his care for up to 50 years. In “this naturalistic study,” he specifically asked the patients to rate their adherence to antipsychotics and to provide a global assessment of their life satisfaction, both on a scale of 1-10.
“What I found in a relatively large sample was that the more adherent patients were to their medication, the more likely they were to report adequate satisfaction with their life,” Dr. Glick said. For those who were not adherent, life in general “has been a disaster.”
This finding is not entirely surprising given the power of antipsychotics to change thinking. However, for those engaged in the immediate task of controlling acute symptoms, the importance of chronicity might not be given adequate emphasis. This requires educating patients and their families about the need to embark on lifetime treatment, Dr. Glick said. Like a diagnosis of diabetes, a diagnosis of schizophrenia means constant vigilance for manifestations of disease and appropriate adjustments of therapy to improve long-term outcomes.
Since evaluating the relationship between medication adherence and long-term outcomes in patients with schizophrenia treated at Stanford, the same type of evaluation was conducted with population samples from the Veterans Affairs system and from China. The data “show exactly the same thing,” Dr. Glick said.
It is important to use every available resource in helping patients recognize and deal with schizophrenia chronicity.
Earlier in his career, Dr. Glick participated in a randomized clinical trial of hospitalization for patients with schizophrenia. Recounting that experience, he reported that he was struck by the improvement in outcomes among patients who grasped that schizophrenia must be approached as a chronic disease.
“Once the patient understood what they had, they were much more apt to be adherent and to stay on their medication for their lifetime,” Dr. Glick reported. Although there is evidence that identifying an effective antipsychotic is key to disease control, “you have to talk to the patient, not just throw a medicine at them,” he said. This makes educating patients and families the key step in embarking on indefinite, close disease monitoring.
Control of schizophrenia over time is likely to vary as symptoms wax and wane, but this is true of other chronic disease processes. Diabetes, for example, requires frequent monitoring for and adjustment of blood glucose. Often medications for diabetes must be intensified or switched. The monitoring and management of schizophrenia is analogous.
One strategy for improving control of schizophrenia is to educate patients about this concept. Approaching schizophrenia as a chronic illness like other diseases that require lifetime drugs will help reduce the crises and the adverse effects associated with nonadherence to tight management, Dr. Glick maintained.
Dr. Glick reported financial relationships with Forum Pharmaceuticals, Johnson & Johnson, Neurocrine, Sunovion, and Teva.
TAMPA – The secret to optimal long-term disease control in schizophrenia is to implement the same type of continuous and close management provided to other chronic diseases, like hypertension or inflammatory bowel disease, according to a lecture delivered at the annual meeting of the American College of Psychiatrists.
In the Dean Award Lecture – a talk characterized as “a stroll through the long-term understanding of the treatment of schizophrenia” – Ira D. Glick, MD, said that, although antipsychotics provide the foundation of disease control, patients and families need to understand and respect disease chronicity.
“In the last 5 or 6 years, I did something that no one has ever done before. I looked at the outcomes of patients treated for decades,” Dr. Glick recounted. Specifically, he contacted patients who had been in his care for up to 50 years. In “this naturalistic study,” he specifically asked the patients to rate their adherence to antipsychotics and to provide a global assessment of their life satisfaction, both on a scale of 1-10.
“What I found in a relatively large sample was that the more adherent patients were to their medication, the more likely they were to report adequate satisfaction with their life,” Dr. Glick said. For those who were not adherent, life in general “has been a disaster.”
This finding is not entirely surprising given the power of antipsychotics to change thinking. However, for those engaged in the immediate task of controlling acute symptoms, the importance of chronicity might not be given adequate emphasis. This requires educating patients and their families about the need to embark on lifetime treatment, Dr. Glick said. Like a diagnosis of diabetes, a diagnosis of schizophrenia means constant vigilance for manifestations of disease and appropriate adjustments of therapy to improve long-term outcomes.
Since evaluating the relationship between medication adherence and long-term outcomes in patients with schizophrenia treated at Stanford, the same type of evaluation was conducted with population samples from the Veterans Affairs system and from China. The data “show exactly the same thing,” Dr. Glick said.
It is important to use every available resource in helping patients recognize and deal with schizophrenia chronicity.
Earlier in his career, Dr. Glick participated in a randomized clinical trial of hospitalization for patients with schizophrenia. Recounting that experience, he reported that he was struck by the improvement in outcomes among patients who grasped that schizophrenia must be approached as a chronic disease.
“Once the patient understood what they had, they were much more apt to be adherent and to stay on their medication for their lifetime,” Dr. Glick reported. Although there is evidence that identifying an effective antipsychotic is key to disease control, “you have to talk to the patient, not just throw a medicine at them,” he said. This makes educating patients and families the key step in embarking on indefinite, close disease monitoring.
Control of schizophrenia over time is likely to vary as symptoms wax and wane, but this is true of other chronic disease processes. Diabetes, for example, requires frequent monitoring for and adjustment of blood glucose. Often medications for diabetes must be intensified or switched. The monitoring and management of schizophrenia is analogous.
One strategy for improving control of schizophrenia is to educate patients about this concept. Approaching schizophrenia as a chronic illness like other diseases that require lifetime drugs will help reduce the crises and the adverse effects associated with nonadherence to tight management, Dr. Glick maintained.
Dr. Glick reported financial relationships with Forum Pharmaceuticals, Johnson & Johnson, Neurocrine, Sunovion, and Teva.
REPORTING FROM THE COLLEGE 2018
Demand, not need, may drive further expansion of telepsychiatry
TAMPA – The growth of telepsychiatry has been driven largely by needs of access, particularly in rural areas without specialists. But telemedicine is convenient, and those growing up with computers, smartphones, and other technology are going to demand this type of access to their clinicians, according to a leader of a course on telepsychiatry at the annual meeting of the American College of Psychiatrists.
“Digital natives – the consumers – are going to drive the use of technology more and more. They are used to videoconferencing. They want to see their doctors over video. They want to communicate via text and email. They want that convenience, and they are much more comfortable with it,” said James (Jay) H. Shore, MD, director of telemedicine at the Johnson Depression Center at the University of Colorado Denver.
Meanwhile, telepsychiatry is evolving, allowing for more sophisticated approaches and expanded applications.
“When we started doing video conferencing technologies, we basically were taking what we do in person and just doing that over video,” Dr. Shore said. “Where we are now, .”
A prolific author on the topic of telepsychiatry and long involved in this practice, Dr. Shore has said that the widespread introduction of fiber optic networks and other technological advances over the last 15 years has advanced all forms of digital technology. These are enabling and will likely accelerate synergies possible with integration of different platforms, such as electronic health records, patient portals, videoconferencing, and various methods of communication.
In his own experience, which includes providing remote services from his office in Denver to native populations in Alaska, he has discovered some unexpected advantages to telepsychiatry. For example, some victims recounting histories of domestic abuse feel more secure during videoconferencing than during a face-to-face interview, facilitating capture of a complete history. In general, he now prefers telepsychiatry in those situations.
As telepsychiatry advances, it will be increasingly integrated into hybrid models of care that involve communicating with both the patient and other clinicians over multiple platforms (for example, in-person, video, patient portals). This is not just relevant to patients in a geographically distant facility. With greater acceptance and integration, videoconferencing will be part of this mix of communication tools that might also include in-person consultations. The goal will be to use the most convenient communication strategies to coordinate the diagnosis, a treatment plan, and follow-up.
“The neat thing about telepsychiatry is really the virtual teaming models that we can create,” Dr. Shore said. However, he acknowledged that this type of team participation requires an adjustment in reimbursement models for psychiatrists that traditionally have centered on psychopharmacology. The problem with the models limited to prescription writing is that they “do not tap into the psychiatrist’s leadership of the mental health team, knowledge of human behavior, and they are not, at least for me, as personally rewarding.”
He believes that the growing array of technologies contained in telepsychiatry will increase opportunities for psychiatrists in a host of such settings such as crisis management in emergency care settings or coordination of psychiatric care in residential treatment settings.
The expansion of telemedicine already is reflected in the growing number of companies marketing services directly to consumers. Dr. Shore listed several offering virtual health care that may contribute to both acceptance and demand for medical care delivered digitally. Although telepsychiatry already is associated with many effective applications, Dr. Shore reiterated that consumer demand will be a driver for further expansion of telemedicine in general.
He also emphasized that change involving digital advances in psychiatry is inevitable. According to Dr. Shore, artificial intelligence, virtual reality treatments, and social networking are among potential tools for altering care. Inside and outside of medicine, the pace of change driven by advances in digital exchange of information has been and is expected to continue to be brisk.
“Then there is the technology that is going to disrupt us all that we can’t see coming,” Dr. Shore said. “It is being invented right now in somebody’s garage in Palo Alto.”
Dr. Shore reported that he is chief medical officer of AccessCare Services, which provides telehealth services and technologies.
TAMPA – The growth of telepsychiatry has been driven largely by needs of access, particularly in rural areas without specialists. But telemedicine is convenient, and those growing up with computers, smartphones, and other technology are going to demand this type of access to their clinicians, according to a leader of a course on telepsychiatry at the annual meeting of the American College of Psychiatrists.
“Digital natives – the consumers – are going to drive the use of technology more and more. They are used to videoconferencing. They want to see their doctors over video. They want to communicate via text and email. They want that convenience, and they are much more comfortable with it,” said James (Jay) H. Shore, MD, director of telemedicine at the Johnson Depression Center at the University of Colorado Denver.
Meanwhile, telepsychiatry is evolving, allowing for more sophisticated approaches and expanded applications.
“When we started doing video conferencing technologies, we basically were taking what we do in person and just doing that over video,” Dr. Shore said. “Where we are now, .”
A prolific author on the topic of telepsychiatry and long involved in this practice, Dr. Shore has said that the widespread introduction of fiber optic networks and other technological advances over the last 15 years has advanced all forms of digital technology. These are enabling and will likely accelerate synergies possible with integration of different platforms, such as electronic health records, patient portals, videoconferencing, and various methods of communication.
In his own experience, which includes providing remote services from his office in Denver to native populations in Alaska, he has discovered some unexpected advantages to telepsychiatry. For example, some victims recounting histories of domestic abuse feel more secure during videoconferencing than during a face-to-face interview, facilitating capture of a complete history. In general, he now prefers telepsychiatry in those situations.
As telepsychiatry advances, it will be increasingly integrated into hybrid models of care that involve communicating with both the patient and other clinicians over multiple platforms (for example, in-person, video, patient portals). This is not just relevant to patients in a geographically distant facility. With greater acceptance and integration, videoconferencing will be part of this mix of communication tools that might also include in-person consultations. The goal will be to use the most convenient communication strategies to coordinate the diagnosis, a treatment plan, and follow-up.
“The neat thing about telepsychiatry is really the virtual teaming models that we can create,” Dr. Shore said. However, he acknowledged that this type of team participation requires an adjustment in reimbursement models for psychiatrists that traditionally have centered on psychopharmacology. The problem with the models limited to prescription writing is that they “do not tap into the psychiatrist’s leadership of the mental health team, knowledge of human behavior, and they are not, at least for me, as personally rewarding.”
He believes that the growing array of technologies contained in telepsychiatry will increase opportunities for psychiatrists in a host of such settings such as crisis management in emergency care settings or coordination of psychiatric care in residential treatment settings.
The expansion of telemedicine already is reflected in the growing number of companies marketing services directly to consumers. Dr. Shore listed several offering virtual health care that may contribute to both acceptance and demand for medical care delivered digitally. Although telepsychiatry already is associated with many effective applications, Dr. Shore reiterated that consumer demand will be a driver for further expansion of telemedicine in general.
He also emphasized that change involving digital advances in psychiatry is inevitable. According to Dr. Shore, artificial intelligence, virtual reality treatments, and social networking are among potential tools for altering care. Inside and outside of medicine, the pace of change driven by advances in digital exchange of information has been and is expected to continue to be brisk.
“Then there is the technology that is going to disrupt us all that we can’t see coming,” Dr. Shore said. “It is being invented right now in somebody’s garage in Palo Alto.”
Dr. Shore reported that he is chief medical officer of AccessCare Services, which provides telehealth services and technologies.
TAMPA – The growth of telepsychiatry has been driven largely by needs of access, particularly in rural areas without specialists. But telemedicine is convenient, and those growing up with computers, smartphones, and other technology are going to demand this type of access to their clinicians, according to a leader of a course on telepsychiatry at the annual meeting of the American College of Psychiatrists.
“Digital natives – the consumers – are going to drive the use of technology more and more. They are used to videoconferencing. They want to see their doctors over video. They want to communicate via text and email. They want that convenience, and they are much more comfortable with it,” said James (Jay) H. Shore, MD, director of telemedicine at the Johnson Depression Center at the University of Colorado Denver.
Meanwhile, telepsychiatry is evolving, allowing for more sophisticated approaches and expanded applications.
“When we started doing video conferencing technologies, we basically were taking what we do in person and just doing that over video,” Dr. Shore said. “Where we are now, .”
A prolific author on the topic of telepsychiatry and long involved in this practice, Dr. Shore has said that the widespread introduction of fiber optic networks and other technological advances over the last 15 years has advanced all forms of digital technology. These are enabling and will likely accelerate synergies possible with integration of different platforms, such as electronic health records, patient portals, videoconferencing, and various methods of communication.
In his own experience, which includes providing remote services from his office in Denver to native populations in Alaska, he has discovered some unexpected advantages to telepsychiatry. For example, some victims recounting histories of domestic abuse feel more secure during videoconferencing than during a face-to-face interview, facilitating capture of a complete history. In general, he now prefers telepsychiatry in those situations.
As telepsychiatry advances, it will be increasingly integrated into hybrid models of care that involve communicating with both the patient and other clinicians over multiple platforms (for example, in-person, video, patient portals). This is not just relevant to patients in a geographically distant facility. With greater acceptance and integration, videoconferencing will be part of this mix of communication tools that might also include in-person consultations. The goal will be to use the most convenient communication strategies to coordinate the diagnosis, a treatment plan, and follow-up.
“The neat thing about telepsychiatry is really the virtual teaming models that we can create,” Dr. Shore said. However, he acknowledged that this type of team participation requires an adjustment in reimbursement models for psychiatrists that traditionally have centered on psychopharmacology. The problem with the models limited to prescription writing is that they “do not tap into the psychiatrist’s leadership of the mental health team, knowledge of human behavior, and they are not, at least for me, as personally rewarding.”
He believes that the growing array of technologies contained in telepsychiatry will increase opportunities for psychiatrists in a host of such settings such as crisis management in emergency care settings or coordination of psychiatric care in residential treatment settings.
The expansion of telemedicine already is reflected in the growing number of companies marketing services directly to consumers. Dr. Shore listed several offering virtual health care that may contribute to both acceptance and demand for medical care delivered digitally. Although telepsychiatry already is associated with many effective applications, Dr. Shore reiterated that consumer demand will be a driver for further expansion of telemedicine in general.
He also emphasized that change involving digital advances in psychiatry is inevitable. According to Dr. Shore, artificial intelligence, virtual reality treatments, and social networking are among potential tools for altering care. Inside and outside of medicine, the pace of change driven by advances in digital exchange of information has been and is expected to continue to be brisk.
“Then there is the technology that is going to disrupt us all that we can’t see coming,” Dr. Shore said. “It is being invented right now in somebody’s garage in Palo Alto.”
Dr. Shore reported that he is chief medical officer of AccessCare Services, which provides telehealth services and technologies.
REPORTING FROM THE COLLEGE 2018
Deeply entrenched gender bias in academic medicine is treatable
TAMPA, FLA. – Gender bias that disadvantages women from rising in academic medicine might require specific habit-changing strategies rather than efforts that draw on goodwill alone, according to new follow-up data from a randomized trial discussed and reevaluated at the annual meeting of the American College of Psychiatrists.
One premise of this trial, supported by other research, is that entrenched gender stereotypes drive both male and female behavior and must be addressed directly for change, said Molly Carnes, MD, professor of psychiatry at the University of Wisconsin, Madison.
The initial results of the trial, which randomized academic departments at the University of Wisconsin to participate in habit-changing workshops or to serve as controls, were published almost 3 years ago (Acad Med. 2015 Feb;90[2]:221-30). It is the most recent follow-up (Devine et al. J Exp Soc Psychol. 2017 Nov;73:211-5) that corroborates that long-term changes are possible with intervention.
The published findings showed that when 1,137 faculty members from 46 departments in the experimental arm were compared with 1,153 faculty members from 46 departments in the control arm, there were significant improvements in the experimental arm in surveyed attitudes reflecting personal bias awareness (P = .001) and willingness to support gender equity (P = .013).
These changes in attitude translated into concrete changes in new female faculty hires in the most recent analysis. From 32% in a 2-year period before the workshops, the new female hires climbed to 46% in the 2-year period after the workshops – a relative increase of 44% in the departments participating in the experimental arm. In the control departments, female new faculty hires remained at 32% in both time periods.
“Basically, there are 20 new women faculty members at the University of Wisconsin because of this study,” Dr. Carnes said.
. The result was a fundamental change in culture within departments randomized to the experimental arm, according to data generated by a variety of study analyses.
“When we looked at questions about department climate, we found that both male and female faculty members in the experimental groups were significantly more likely to say they fit in their department, they felt respected for their research and scholarship by their colleagues, and they felt comfortable raising personal and family issues even if they conflicted with departmental activities,” Dr. Carnes said.
This general attitude change is important, because Dr. Carnes emphasized that women share the cultural biases that can result in reduced female career opportunities in clinical and academic medicine. In addition, women generally are aware that stereotypical positive “agentic” adjectives for men, such as decisive, competitive, and ambitious, often are viewed negatively and generate backlash when applied to women. They therefore act on this awareness.
“Stereotype-based bias is a habit that can be broken, but it requires more than good intentions,” said Dr. Carnes, who emphasized that “gender-based assumptions and stereotypes are deeply embedded in the patterns of thinking of both men and women.”
As one example, Dr. Carnes cited her work evaluating female resident behavior when leading in-hospital code resuscitations. There are data to show that there is no difference in the effectiveness of male and female resident code leaders, but women typically feel that the assertive, aggressive behavior required for code leadership is “counternormative.” After the code, some women feel compelled to apologize to team members for being demanding or assertive, a step that Dr. Carnes attributed at least in part to fear of backlash from stepping out of gender-expected behavior.
The fix is not necessarily suppression of gender-related attributes. Dr. Carnes cited evidence that the stereotypical positive communal adjectives for women, such as nurturing, supportive, and sympathetic, might explain why studies suggest that women are more likely than men to be transformational leaders who inspire team members to contribute beyond their own self-interest in achieving goals.
Ultimately, the fix is replacement of stereotypes that impair men as well as women from defusing biases that “lead to subtle unintentional advantages in academic career advancement for Jack not afforded to Jill,” Dr. Carnes said. Based on the low numbers of female leaders in academic medicine decades after medical schools began enrolling women in substantial numbers, she concluded that meaningful change in gender bias is not likely to occur without implementation of specific proactive strategies aimed at challenging current perceptions. Her published study confirms that such strategies can help.
Dr. Carnes reported no conflicts of interest.
Patricia Devine et al. in a recent study published in the Journal of Experimental Social Psychology tested the effect of one 2.5-hour workshop that sought to positively influence the mental habit of gender bias, which exists in our academic world (and elsewhere) in both men and women.
Bevra H. Hahn, MD, is Distinguished Professor of Medicine (emeritus) at the University of California, Los Angeles.
Patricia Devine et al. in a recent study published in the Journal of Experimental Social Psychology tested the effect of one 2.5-hour workshop that sought to positively influence the mental habit of gender bias, which exists in our academic world (and elsewhere) in both men and women.
Bevra H. Hahn, MD, is Distinguished Professor of Medicine (emeritus) at the University of California, Los Angeles.
Patricia Devine et al. in a recent study published in the Journal of Experimental Social Psychology tested the effect of one 2.5-hour workshop that sought to positively influence the mental habit of gender bias, which exists in our academic world (and elsewhere) in both men and women.
Bevra H. Hahn, MD, is Distinguished Professor of Medicine (emeritus) at the University of California, Los Angeles.
TAMPA, FLA. – Gender bias that disadvantages women from rising in academic medicine might require specific habit-changing strategies rather than efforts that draw on goodwill alone, according to new follow-up data from a randomized trial discussed and reevaluated at the annual meeting of the American College of Psychiatrists.
One premise of this trial, supported by other research, is that entrenched gender stereotypes drive both male and female behavior and must be addressed directly for change, said Molly Carnes, MD, professor of psychiatry at the University of Wisconsin, Madison.
The initial results of the trial, which randomized academic departments at the University of Wisconsin to participate in habit-changing workshops or to serve as controls, were published almost 3 years ago (Acad Med. 2015 Feb;90[2]:221-30). It is the most recent follow-up (Devine et al. J Exp Soc Psychol. 2017 Nov;73:211-5) that corroborates that long-term changes are possible with intervention.
The published findings showed that when 1,137 faculty members from 46 departments in the experimental arm were compared with 1,153 faculty members from 46 departments in the control arm, there were significant improvements in the experimental arm in surveyed attitudes reflecting personal bias awareness (P = .001) and willingness to support gender equity (P = .013).
These changes in attitude translated into concrete changes in new female faculty hires in the most recent analysis. From 32% in a 2-year period before the workshops, the new female hires climbed to 46% in the 2-year period after the workshops – a relative increase of 44% in the departments participating in the experimental arm. In the control departments, female new faculty hires remained at 32% in both time periods.
“Basically, there are 20 new women faculty members at the University of Wisconsin because of this study,” Dr. Carnes said.
. The result was a fundamental change in culture within departments randomized to the experimental arm, according to data generated by a variety of study analyses.
“When we looked at questions about department climate, we found that both male and female faculty members in the experimental groups were significantly more likely to say they fit in their department, they felt respected for their research and scholarship by their colleagues, and they felt comfortable raising personal and family issues even if they conflicted with departmental activities,” Dr. Carnes said.
This general attitude change is important, because Dr. Carnes emphasized that women share the cultural biases that can result in reduced female career opportunities in clinical and academic medicine. In addition, women generally are aware that stereotypical positive “agentic” adjectives for men, such as decisive, competitive, and ambitious, often are viewed negatively and generate backlash when applied to women. They therefore act on this awareness.
“Stereotype-based bias is a habit that can be broken, but it requires more than good intentions,” said Dr. Carnes, who emphasized that “gender-based assumptions and stereotypes are deeply embedded in the patterns of thinking of both men and women.”
As one example, Dr. Carnes cited her work evaluating female resident behavior when leading in-hospital code resuscitations. There are data to show that there is no difference in the effectiveness of male and female resident code leaders, but women typically feel that the assertive, aggressive behavior required for code leadership is “counternormative.” After the code, some women feel compelled to apologize to team members for being demanding or assertive, a step that Dr. Carnes attributed at least in part to fear of backlash from stepping out of gender-expected behavior.
The fix is not necessarily suppression of gender-related attributes. Dr. Carnes cited evidence that the stereotypical positive communal adjectives for women, such as nurturing, supportive, and sympathetic, might explain why studies suggest that women are more likely than men to be transformational leaders who inspire team members to contribute beyond their own self-interest in achieving goals.
Ultimately, the fix is replacement of stereotypes that impair men as well as women from defusing biases that “lead to subtle unintentional advantages in academic career advancement for Jack not afforded to Jill,” Dr. Carnes said. Based on the low numbers of female leaders in academic medicine decades after medical schools began enrolling women in substantial numbers, she concluded that meaningful change in gender bias is not likely to occur without implementation of specific proactive strategies aimed at challenging current perceptions. Her published study confirms that such strategies can help.
Dr. Carnes reported no conflicts of interest.
TAMPA, FLA. – Gender bias that disadvantages women from rising in academic medicine might require specific habit-changing strategies rather than efforts that draw on goodwill alone, according to new follow-up data from a randomized trial discussed and reevaluated at the annual meeting of the American College of Psychiatrists.
One premise of this trial, supported by other research, is that entrenched gender stereotypes drive both male and female behavior and must be addressed directly for change, said Molly Carnes, MD, professor of psychiatry at the University of Wisconsin, Madison.
The initial results of the trial, which randomized academic departments at the University of Wisconsin to participate in habit-changing workshops or to serve as controls, were published almost 3 years ago (Acad Med. 2015 Feb;90[2]:221-30). It is the most recent follow-up (Devine et al. J Exp Soc Psychol. 2017 Nov;73:211-5) that corroborates that long-term changes are possible with intervention.
The published findings showed that when 1,137 faculty members from 46 departments in the experimental arm were compared with 1,153 faculty members from 46 departments in the control arm, there were significant improvements in the experimental arm in surveyed attitudes reflecting personal bias awareness (P = .001) and willingness to support gender equity (P = .013).
These changes in attitude translated into concrete changes in new female faculty hires in the most recent analysis. From 32% in a 2-year period before the workshops, the new female hires climbed to 46% in the 2-year period after the workshops – a relative increase of 44% in the departments participating in the experimental arm. In the control departments, female new faculty hires remained at 32% in both time periods.
“Basically, there are 20 new women faculty members at the University of Wisconsin because of this study,” Dr. Carnes said.
. The result was a fundamental change in culture within departments randomized to the experimental arm, according to data generated by a variety of study analyses.
“When we looked at questions about department climate, we found that both male and female faculty members in the experimental groups were significantly more likely to say they fit in their department, they felt respected for their research and scholarship by their colleagues, and they felt comfortable raising personal and family issues even if they conflicted with departmental activities,” Dr. Carnes said.
This general attitude change is important, because Dr. Carnes emphasized that women share the cultural biases that can result in reduced female career opportunities in clinical and academic medicine. In addition, women generally are aware that stereotypical positive “agentic” adjectives for men, such as decisive, competitive, and ambitious, often are viewed negatively and generate backlash when applied to women. They therefore act on this awareness.
“Stereotype-based bias is a habit that can be broken, but it requires more than good intentions,” said Dr. Carnes, who emphasized that “gender-based assumptions and stereotypes are deeply embedded in the patterns of thinking of both men and women.”
As one example, Dr. Carnes cited her work evaluating female resident behavior when leading in-hospital code resuscitations. There are data to show that there is no difference in the effectiveness of male and female resident code leaders, but women typically feel that the assertive, aggressive behavior required for code leadership is “counternormative.” After the code, some women feel compelled to apologize to team members for being demanding or assertive, a step that Dr. Carnes attributed at least in part to fear of backlash from stepping out of gender-expected behavior.
The fix is not necessarily suppression of gender-related attributes. Dr. Carnes cited evidence that the stereotypical positive communal adjectives for women, such as nurturing, supportive, and sympathetic, might explain why studies suggest that women are more likely than men to be transformational leaders who inspire team members to contribute beyond their own self-interest in achieving goals.
Ultimately, the fix is replacement of stereotypes that impair men as well as women from defusing biases that “lead to subtle unintentional advantages in academic career advancement for Jack not afforded to Jill,” Dr. Carnes said. Based on the low numbers of female leaders in academic medicine decades after medical schools began enrolling women in substantial numbers, she concluded that meaningful change in gender bias is not likely to occur without implementation of specific proactive strategies aimed at challenging current perceptions. Her published study confirms that such strategies can help.
Dr. Carnes reported no conflicts of interest.
REPORTING FROM THE COLLEGE 2018
Goldwater Rule should be modified, debate audience at The College agrees
TAMPA, FLA. – Most psychiatrists believe that the so-called “Goldwater Rule” should be amended if an informal poll conducted at the annual meeting of the American College of Psychiatrists reflects dominant opinion.
The poll was conducted at the end of a debate between Nada L. Stotland, MD, who argued for no change, and Steven S. Sharfstein, MD, who argued that the ethical standard may have made sense when created in 1973 “but is now outmoded.”
The American Psychiatric Association introduced what is widely known as the Goldwater Rule into the APA code of ethics following an infamous survey of psychiatrists published in 1964. In that survey, the respondents overwhelmingly expressed the opinion that Barry Goldwater, the Arizona senator and 1964 candidate for president of the United States, was unfit to serve, an outcome that many considered an embarrassment for the APA.
As written, the ethical standard introduced by the APA proscribes psychiatrists from pronouncing a diagnosis of mental illness in public figures who they have not examined. The standard was later amended to disallow any professional opinion on mental health in public figures, not just a diagnosis.
This standard, always controversial, has been increasingly challenged as a result of concerns expressed frequently in public forums about the mental health of the current president. The moderator of the debate, John M. Oldman, MD, chair for personality disorders in the department of psychiatry and behavioral sciences at Baylor College of Medicine, Houston, commented that President Donald Trump “may be the death of the Goldwater rule.”
Even though not all agreed that a psychiatric diagnosis requires a face-to-face evaluation, the debate centered on the justification for banning psychiatrists from offering any opinion about the mental health of a public figure. Can an opinion be justified on the basis of First Amendment guarantees of free speech if the speaker identifies him or herself as a psychiatrist?
Dr. Sharfstein, who is president emeritus, Sheppard Pratt Health System, Baltimore, concluded that this prohibition is too far reaching. By his interpretation, psychiatrists who call a public figure “a jerk” are potentially violating the Goldwater Rule. Although he conceded that he is sensitive to the etiquette of demeaning public figures when speaking in the capacity of a psychiatrist, he said that banning the expression of opinions “is unenforceable.”
Dr. Stotland, professor of psychiatry at Rush Medical College, Chicago, disagreed. She argued that comments on mental health status expressed by a psychiatrist carry different weight than other citizens. Like boxers, whose fists are considered legal weapons in some states, a psychiatrist “should give up the right to express casual opinions” about psychopathology in a public figure, she said.
As professional opinions will almost certainly differ between psychiatrists, Dr. Stotland also suggested that an inevitable variety of opinions expressed by different psychiatrists about a public figure is not likely to contribute usefully to the general discourse. “Dissension in our public remarks undermines the credibility of our profession,” she said.
Although Dr. Sharfstein questioned whether psychiatrists have an ethical or moral obligation to “make the profession look good,” he conceded that there is room for civility when making pronouncements about the mental health status of public figures. Nevertheless, he reiterated that a ban on the expression of opinion is untenable. Citing the words of another critic of the Goldwater Rule, he argued, “Every psychiatrist has a first amendment right to make an idiot of themselves.”
For her part, Dr. Stotland suggested it is reasonable to ask whether psychiatrists questioning the mental health of a political leader are offering “a diagnosis or an accusation.” She cautioned about “using psychiatry as a weapon” in political debate.
Distinguishing professional from political opinions when speaking about mental health is a “slippery slope,” agreed Dr. Sharfstein, but he expressed concern about the ethics of not speaking out when a psychiatrist is convinced that a leader is psychologically unstable.
In the informal vote following the debate, the audience was provided with four options: retain the Goldwater Rule, abandon the Goldwater Rule, modify the Goldwater Rule, or abstain from voting. A large majority of the audience voted for a modification, overwhelming all three of the other options. Yet, it could not be determined from the show of hands what specific changes the audience members had in mind.
Dr. Oldham, Dr. Sharfstein, and Dr. Stotland reported no conflicts of interest relevant to this topic.
TAMPA, FLA. – Most psychiatrists believe that the so-called “Goldwater Rule” should be amended if an informal poll conducted at the annual meeting of the American College of Psychiatrists reflects dominant opinion.
The poll was conducted at the end of a debate between Nada L. Stotland, MD, who argued for no change, and Steven S. Sharfstein, MD, who argued that the ethical standard may have made sense when created in 1973 “but is now outmoded.”
The American Psychiatric Association introduced what is widely known as the Goldwater Rule into the APA code of ethics following an infamous survey of psychiatrists published in 1964. In that survey, the respondents overwhelmingly expressed the opinion that Barry Goldwater, the Arizona senator and 1964 candidate for president of the United States, was unfit to serve, an outcome that many considered an embarrassment for the APA.
As written, the ethical standard introduced by the APA proscribes psychiatrists from pronouncing a diagnosis of mental illness in public figures who they have not examined. The standard was later amended to disallow any professional opinion on mental health in public figures, not just a diagnosis.
This standard, always controversial, has been increasingly challenged as a result of concerns expressed frequently in public forums about the mental health of the current president. The moderator of the debate, John M. Oldman, MD, chair for personality disorders in the department of psychiatry and behavioral sciences at Baylor College of Medicine, Houston, commented that President Donald Trump “may be the death of the Goldwater rule.”
Even though not all agreed that a psychiatric diagnosis requires a face-to-face evaluation, the debate centered on the justification for banning psychiatrists from offering any opinion about the mental health of a public figure. Can an opinion be justified on the basis of First Amendment guarantees of free speech if the speaker identifies him or herself as a psychiatrist?
Dr. Sharfstein, who is president emeritus, Sheppard Pratt Health System, Baltimore, concluded that this prohibition is too far reaching. By his interpretation, psychiatrists who call a public figure “a jerk” are potentially violating the Goldwater Rule. Although he conceded that he is sensitive to the etiquette of demeaning public figures when speaking in the capacity of a psychiatrist, he said that banning the expression of opinions “is unenforceable.”
Dr. Stotland, professor of psychiatry at Rush Medical College, Chicago, disagreed. She argued that comments on mental health status expressed by a psychiatrist carry different weight than other citizens. Like boxers, whose fists are considered legal weapons in some states, a psychiatrist “should give up the right to express casual opinions” about psychopathology in a public figure, she said.
As professional opinions will almost certainly differ between psychiatrists, Dr. Stotland also suggested that an inevitable variety of opinions expressed by different psychiatrists about a public figure is not likely to contribute usefully to the general discourse. “Dissension in our public remarks undermines the credibility of our profession,” she said.
Although Dr. Sharfstein questioned whether psychiatrists have an ethical or moral obligation to “make the profession look good,” he conceded that there is room for civility when making pronouncements about the mental health status of public figures. Nevertheless, he reiterated that a ban on the expression of opinion is untenable. Citing the words of another critic of the Goldwater Rule, he argued, “Every psychiatrist has a first amendment right to make an idiot of themselves.”
For her part, Dr. Stotland suggested it is reasonable to ask whether psychiatrists questioning the mental health of a political leader are offering “a diagnosis or an accusation.” She cautioned about “using psychiatry as a weapon” in political debate.
Distinguishing professional from political opinions when speaking about mental health is a “slippery slope,” agreed Dr. Sharfstein, but he expressed concern about the ethics of not speaking out when a psychiatrist is convinced that a leader is psychologically unstable.
In the informal vote following the debate, the audience was provided with four options: retain the Goldwater Rule, abandon the Goldwater Rule, modify the Goldwater Rule, or abstain from voting. A large majority of the audience voted for a modification, overwhelming all three of the other options. Yet, it could not be determined from the show of hands what specific changes the audience members had in mind.
Dr. Oldham, Dr. Sharfstein, and Dr. Stotland reported no conflicts of interest relevant to this topic.
TAMPA, FLA. – Most psychiatrists believe that the so-called “Goldwater Rule” should be amended if an informal poll conducted at the annual meeting of the American College of Psychiatrists reflects dominant opinion.
The poll was conducted at the end of a debate between Nada L. Stotland, MD, who argued for no change, and Steven S. Sharfstein, MD, who argued that the ethical standard may have made sense when created in 1973 “but is now outmoded.”
The American Psychiatric Association introduced what is widely known as the Goldwater Rule into the APA code of ethics following an infamous survey of psychiatrists published in 1964. In that survey, the respondents overwhelmingly expressed the opinion that Barry Goldwater, the Arizona senator and 1964 candidate for president of the United States, was unfit to serve, an outcome that many considered an embarrassment for the APA.
As written, the ethical standard introduced by the APA proscribes psychiatrists from pronouncing a diagnosis of mental illness in public figures who they have not examined. The standard was later amended to disallow any professional opinion on mental health in public figures, not just a diagnosis.
This standard, always controversial, has been increasingly challenged as a result of concerns expressed frequently in public forums about the mental health of the current president. The moderator of the debate, John M. Oldman, MD, chair for personality disorders in the department of psychiatry and behavioral sciences at Baylor College of Medicine, Houston, commented that President Donald Trump “may be the death of the Goldwater rule.”
Even though not all agreed that a psychiatric diagnosis requires a face-to-face evaluation, the debate centered on the justification for banning psychiatrists from offering any opinion about the mental health of a public figure. Can an opinion be justified on the basis of First Amendment guarantees of free speech if the speaker identifies him or herself as a psychiatrist?
Dr. Sharfstein, who is president emeritus, Sheppard Pratt Health System, Baltimore, concluded that this prohibition is too far reaching. By his interpretation, psychiatrists who call a public figure “a jerk” are potentially violating the Goldwater Rule. Although he conceded that he is sensitive to the etiquette of demeaning public figures when speaking in the capacity of a psychiatrist, he said that banning the expression of opinions “is unenforceable.”
Dr. Stotland, professor of psychiatry at Rush Medical College, Chicago, disagreed. She argued that comments on mental health status expressed by a psychiatrist carry different weight than other citizens. Like boxers, whose fists are considered legal weapons in some states, a psychiatrist “should give up the right to express casual opinions” about psychopathology in a public figure, she said.
As professional opinions will almost certainly differ between psychiatrists, Dr. Stotland also suggested that an inevitable variety of opinions expressed by different psychiatrists about a public figure is not likely to contribute usefully to the general discourse. “Dissension in our public remarks undermines the credibility of our profession,” she said.
Although Dr. Sharfstein questioned whether psychiatrists have an ethical or moral obligation to “make the profession look good,” he conceded that there is room for civility when making pronouncements about the mental health status of public figures. Nevertheless, he reiterated that a ban on the expression of opinion is untenable. Citing the words of another critic of the Goldwater Rule, he argued, “Every psychiatrist has a first amendment right to make an idiot of themselves.”
For her part, Dr. Stotland suggested it is reasonable to ask whether psychiatrists questioning the mental health of a political leader are offering “a diagnosis or an accusation.” She cautioned about “using psychiatry as a weapon” in political debate.
Distinguishing professional from political opinions when speaking about mental health is a “slippery slope,” agreed Dr. Sharfstein, but he expressed concern about the ethics of not speaking out when a psychiatrist is convinced that a leader is psychologically unstable.
In the informal vote following the debate, the audience was provided with four options: retain the Goldwater Rule, abandon the Goldwater Rule, modify the Goldwater Rule, or abstain from voting. A large majority of the audience voted for a modification, overwhelming all three of the other options. Yet, it could not be determined from the show of hands what specific changes the audience members had in mind.
Dr. Oldham, Dr. Sharfstein, and Dr. Stotland reported no conflicts of interest relevant to this topic.
AT THE COLLEGE 2018
Consultation is key defense against sexual boundary violations in psychiatry
TAMPA, FLA. – Although there are very limited data on the risks, frequency, or consequences of sexual boundary violations in psychiatry, a personal experience evaluating, treating, or consulting in 300 such cases suggests that violators often consider their behavior to be justified, at least initially, according to an overview presented at the annual meeting of the American College of Psychiatrists.
“The capacity for individuals to rationalize their actions is just extraordinary,” said Glen O. Gabbard, MD, of the department of psychiatry and behavioral sciences at Baylor College of Medicine, Houston. He explained that many, if not all, violators are familiar with the reasons that sex between therapists and patients is unethical, but they typically consider their specific case exceptional.
These psychiatrists “will look you straight in the eye when telling you they are in love. They are convinced that there is nothing they can do. There is often no reasoning with these individuals,” Dr. Gabbard said.
Like many of these sexual boundary violations, those driven by the lovesickness syndrome typically reach a sexual relationship slowly. This is the reason that building a consultation into routine practice can be a critical defense against inappropriate treatment relationships, according to Dr. Gabbard. He suggested that it is important for psychiatrists to be open with the consultant therapist about all aspects of treatment, particularly ones that may be unflattering, and selecting a consultant who will not hesitate to challenge questionable behavior.
Self-monitoring questions represent another defense. Therapists will be able to recognize red flags when answering self-posed questions about whether there are aspects of any treatment or patient relationship they would not be willing to share with a colleague, whether there is any part of treatment that they would be unwilling to put in the patient’s chart, whether all treatment activities fit into a therapeutic plan, and whether everything they are doing meets community standards.
One obstacle to understanding the issue of sexual boundary violations is that it has remained “shrouded in secrecy despite a long history of transgressions,” according to Dr. Gabbard. There is very little reliable information about how often it occurs, the most common characteristics of therapists at risk for committing sexual boundary violations, or whether the incidence has been rising, falling, or has remained relatively constant.
In his anecdotal series of cases, Dr. Gabbard noted that 85% of the violators have been male therapists crossing sexual boundaries with female patients, but he cautioned that this might be a skewed sample.
“Males who have sex with female therapists often feel triumphant,” Dr. Gabbard said. This may explain why complaints by male patients against female therapists are relatively uncommon. However, citing several cases, Dr. Gabbard said that the general outrage is typically greater when a female therapist is the perpetrator.
Regardless of the circumstances, sexual relations with a patient are always a breach of fiduciary duty, Dr. Gabbard said. Nothing justifies this behavior. For example, a subsequent marriage between a therapist and his or her patient is not a mitigating proof of a justifiable romance. Rather, not least because of the unequal power dynamics between a therapist and his or her patient, Dr. Gabbard warned that such marriages have a strong potential for adverse long-term consequences for the well being of the patient.
Defenses are needed against sexual boundary violations, because sexual attraction involves complex dynamics with insidious effects on thought processes that are not always clear to the individuals involved. The line between flattery, charm, admiration, and friendliness can blur progressively into a sexualized relationship, particularly if physical contact, such as hugs, provides an opportunity to express sexual attraction.
Clinicians at risk of blurring these lines in the course of their efforts to help a patient should consider a key principle of lifeguarding, Dr. Gabbard said. He explained that lifeguards are taught to make sure they are safe before engaging in a rescue. This reason, according to Dr. Gabbard, is, “Drowning victims can take you with them.”
Dr. Gabbard reported no relevant conflicts of interest.
TAMPA, FLA. – Although there are very limited data on the risks, frequency, or consequences of sexual boundary violations in psychiatry, a personal experience evaluating, treating, or consulting in 300 such cases suggests that violators often consider their behavior to be justified, at least initially, according to an overview presented at the annual meeting of the American College of Psychiatrists.
“The capacity for individuals to rationalize their actions is just extraordinary,” said Glen O. Gabbard, MD, of the department of psychiatry and behavioral sciences at Baylor College of Medicine, Houston. He explained that many, if not all, violators are familiar with the reasons that sex between therapists and patients is unethical, but they typically consider their specific case exceptional.
These psychiatrists “will look you straight in the eye when telling you they are in love. They are convinced that there is nothing they can do. There is often no reasoning with these individuals,” Dr. Gabbard said.
Like many of these sexual boundary violations, those driven by the lovesickness syndrome typically reach a sexual relationship slowly. This is the reason that building a consultation into routine practice can be a critical defense against inappropriate treatment relationships, according to Dr. Gabbard. He suggested that it is important for psychiatrists to be open with the consultant therapist about all aspects of treatment, particularly ones that may be unflattering, and selecting a consultant who will not hesitate to challenge questionable behavior.
Self-monitoring questions represent another defense. Therapists will be able to recognize red flags when answering self-posed questions about whether there are aspects of any treatment or patient relationship they would not be willing to share with a colleague, whether there is any part of treatment that they would be unwilling to put in the patient’s chart, whether all treatment activities fit into a therapeutic plan, and whether everything they are doing meets community standards.
One obstacle to understanding the issue of sexual boundary violations is that it has remained “shrouded in secrecy despite a long history of transgressions,” according to Dr. Gabbard. There is very little reliable information about how often it occurs, the most common characteristics of therapists at risk for committing sexual boundary violations, or whether the incidence has been rising, falling, or has remained relatively constant.
In his anecdotal series of cases, Dr. Gabbard noted that 85% of the violators have been male therapists crossing sexual boundaries with female patients, but he cautioned that this might be a skewed sample.
“Males who have sex with female therapists often feel triumphant,” Dr. Gabbard said. This may explain why complaints by male patients against female therapists are relatively uncommon. However, citing several cases, Dr. Gabbard said that the general outrage is typically greater when a female therapist is the perpetrator.
Regardless of the circumstances, sexual relations with a patient are always a breach of fiduciary duty, Dr. Gabbard said. Nothing justifies this behavior. For example, a subsequent marriage between a therapist and his or her patient is not a mitigating proof of a justifiable romance. Rather, not least because of the unequal power dynamics between a therapist and his or her patient, Dr. Gabbard warned that such marriages have a strong potential for adverse long-term consequences for the well being of the patient.
Defenses are needed against sexual boundary violations, because sexual attraction involves complex dynamics with insidious effects on thought processes that are not always clear to the individuals involved. The line between flattery, charm, admiration, and friendliness can blur progressively into a sexualized relationship, particularly if physical contact, such as hugs, provides an opportunity to express sexual attraction.
Clinicians at risk of blurring these lines in the course of their efforts to help a patient should consider a key principle of lifeguarding, Dr. Gabbard said. He explained that lifeguards are taught to make sure they are safe before engaging in a rescue. This reason, according to Dr. Gabbard, is, “Drowning victims can take you with them.”
Dr. Gabbard reported no relevant conflicts of interest.
TAMPA, FLA. – Although there are very limited data on the risks, frequency, or consequences of sexual boundary violations in psychiatry, a personal experience evaluating, treating, or consulting in 300 such cases suggests that violators often consider their behavior to be justified, at least initially, according to an overview presented at the annual meeting of the American College of Psychiatrists.
“The capacity for individuals to rationalize their actions is just extraordinary,” said Glen O. Gabbard, MD, of the department of psychiatry and behavioral sciences at Baylor College of Medicine, Houston. He explained that many, if not all, violators are familiar with the reasons that sex between therapists and patients is unethical, but they typically consider their specific case exceptional.
These psychiatrists “will look you straight in the eye when telling you they are in love. They are convinced that there is nothing they can do. There is often no reasoning with these individuals,” Dr. Gabbard said.
Like many of these sexual boundary violations, those driven by the lovesickness syndrome typically reach a sexual relationship slowly. This is the reason that building a consultation into routine practice can be a critical defense against inappropriate treatment relationships, according to Dr. Gabbard. He suggested that it is important for psychiatrists to be open with the consultant therapist about all aspects of treatment, particularly ones that may be unflattering, and selecting a consultant who will not hesitate to challenge questionable behavior.
Self-monitoring questions represent another defense. Therapists will be able to recognize red flags when answering self-posed questions about whether there are aspects of any treatment or patient relationship they would not be willing to share with a colleague, whether there is any part of treatment that they would be unwilling to put in the patient’s chart, whether all treatment activities fit into a therapeutic plan, and whether everything they are doing meets community standards.
One obstacle to understanding the issue of sexual boundary violations is that it has remained “shrouded in secrecy despite a long history of transgressions,” according to Dr. Gabbard. There is very little reliable information about how often it occurs, the most common characteristics of therapists at risk for committing sexual boundary violations, or whether the incidence has been rising, falling, or has remained relatively constant.
In his anecdotal series of cases, Dr. Gabbard noted that 85% of the violators have been male therapists crossing sexual boundaries with female patients, but he cautioned that this might be a skewed sample.
“Males who have sex with female therapists often feel triumphant,” Dr. Gabbard said. This may explain why complaints by male patients against female therapists are relatively uncommon. However, citing several cases, Dr. Gabbard said that the general outrage is typically greater when a female therapist is the perpetrator.
Regardless of the circumstances, sexual relations with a patient are always a breach of fiduciary duty, Dr. Gabbard said. Nothing justifies this behavior. For example, a subsequent marriage between a therapist and his or her patient is not a mitigating proof of a justifiable romance. Rather, not least because of the unequal power dynamics between a therapist and his or her patient, Dr. Gabbard warned that such marriages have a strong potential for adverse long-term consequences for the well being of the patient.
Defenses are needed against sexual boundary violations, because sexual attraction involves complex dynamics with insidious effects on thought processes that are not always clear to the individuals involved. The line between flattery, charm, admiration, and friendliness can blur progressively into a sexualized relationship, particularly if physical contact, such as hugs, provides an opportunity to express sexual attraction.
Clinicians at risk of blurring these lines in the course of their efforts to help a patient should consider a key principle of lifeguarding, Dr. Gabbard said. He explained that lifeguards are taught to make sure they are safe before engaging in a rescue. This reason, according to Dr. Gabbard, is, “Drowning victims can take you with them.”
Dr. Gabbard reported no relevant conflicts of interest.
REPORTING FROM THE COLLEGE 2018
Tryptophan depletion may explain high rate of eating disorders in women
TAMPA, FLA. – The far higher rate of eating disorders in women than men appears to be explained at least in part by a greater acute depletion of tryptophan, which is essential for the formation of serotonin, a key mediator of risk, according to a research review presented at the annual meeting of the American College of Psychiatrists.
“The specific vulnerability of women to eating disorders relates to the fact that women’s brains are much more sensitive to dietary intake of tryptophan than are men’s brains,” explained Allan S. Kaplan, MD, senior scientist at the Center for Addiction and Mental Health at the University of Toronto.
“Women are more likely than men to be dieting,” said Dr. Kaplan, walking through the evidence. “Low-calorie diets tend to be high in protein and low in cholesterol and fat. Such diets lead to tryptophan depletion and decreased serotonin synthesis in the brain. Because of lower levels of central serotonin, women are more vulnerable to mood and eating disorders than men.”
Not all women who diet may be vulnerable to this sequence of events. Genetics are likely to be a factor, according to Dr. Kaplan, who said, “Genes load the gun; the environment pulls the trigger.”
However, women do appear to be more susceptible for a number of reasons. For one, the mean rate of serotonin synthesis is 52% higher in normal males than normal females, giving them a greater buffer when dietary intake of tryptophan is low. For another, there is evidence that intake of nutrients most rich in tryptophan, particularly proteins, is typically lower in women than men.
The ratio of females to males for both anorexia nervosa and bulimia nervosa is about 10:1. Although the female-to-male ratio of binge eating is lower at 2:1, women dominate these psychiatric diagnoses. Several environmental factors associated with eating disorders are more closely associated with women than men, including a history of sexual or physical abuse and female preoccupation with body image, but acute tryptophan depletion may be an important factor participating in the translation of risk to an active disease, according to Dr. Kaplan.
Acute tryptophan deficiency may also explain why treatment of eating disorders with SSRIs has been disappointing. With low levels of tryptophan leading to serotonin depletion, “there is no substrate” for drugs administered to increase serotonin-mediated signaling, Dr. Kaplan explained.
Ensuring adequate dietary intake of tryptophan, which is “found mainly in high-protein animal foods,” may be important, even though Dr. Kaplan warned that achieving optimal levels of serotonin “can be challenging from food alone.” Nevertheless, behavioral therapies are commonly effective for eating disorders, presumably at least partially as a result of their ability to normalize diet.
Overall, the tryptophan hypothesis has provided a major shift in the understanding of eating disorders, according to Dr. Kaplan. Further studies are needed, but he said that the key message is that, “For women’s brains, you are what you eat.”
Dr. Kaplan reported no conflicts of interest relevant to this topic.
This story was updated on 2/25/2018.
TAMPA, FLA. – The far higher rate of eating disorders in women than men appears to be explained at least in part by a greater acute depletion of tryptophan, which is essential for the formation of serotonin, a key mediator of risk, according to a research review presented at the annual meeting of the American College of Psychiatrists.
“The specific vulnerability of women to eating disorders relates to the fact that women’s brains are much more sensitive to dietary intake of tryptophan than are men’s brains,” explained Allan S. Kaplan, MD, senior scientist at the Center for Addiction and Mental Health at the University of Toronto.
“Women are more likely than men to be dieting,” said Dr. Kaplan, walking through the evidence. “Low-calorie diets tend to be high in protein and low in cholesterol and fat. Such diets lead to tryptophan depletion and decreased serotonin synthesis in the brain. Because of lower levels of central serotonin, women are more vulnerable to mood and eating disorders than men.”
Not all women who diet may be vulnerable to this sequence of events. Genetics are likely to be a factor, according to Dr. Kaplan, who said, “Genes load the gun; the environment pulls the trigger.”
However, women do appear to be more susceptible for a number of reasons. For one, the mean rate of serotonin synthesis is 52% higher in normal males than normal females, giving them a greater buffer when dietary intake of tryptophan is low. For another, there is evidence that intake of nutrients most rich in tryptophan, particularly proteins, is typically lower in women than men.
The ratio of females to males for both anorexia nervosa and bulimia nervosa is about 10:1. Although the female-to-male ratio of binge eating is lower at 2:1, women dominate these psychiatric diagnoses. Several environmental factors associated with eating disorders are more closely associated with women than men, including a history of sexual or physical abuse and female preoccupation with body image, but acute tryptophan depletion may be an important factor participating in the translation of risk to an active disease, according to Dr. Kaplan.
Acute tryptophan deficiency may also explain why treatment of eating disorders with SSRIs has been disappointing. With low levels of tryptophan leading to serotonin depletion, “there is no substrate” for drugs administered to increase serotonin-mediated signaling, Dr. Kaplan explained.
Ensuring adequate dietary intake of tryptophan, which is “found mainly in high-protein animal foods,” may be important, even though Dr. Kaplan warned that achieving optimal levels of serotonin “can be challenging from food alone.” Nevertheless, behavioral therapies are commonly effective for eating disorders, presumably at least partially as a result of their ability to normalize diet.
Overall, the tryptophan hypothesis has provided a major shift in the understanding of eating disorders, according to Dr. Kaplan. Further studies are needed, but he said that the key message is that, “For women’s brains, you are what you eat.”
Dr. Kaplan reported no conflicts of interest relevant to this topic.
This story was updated on 2/25/2018.
TAMPA, FLA. – The far higher rate of eating disorders in women than men appears to be explained at least in part by a greater acute depletion of tryptophan, which is essential for the formation of serotonin, a key mediator of risk, according to a research review presented at the annual meeting of the American College of Psychiatrists.
“The specific vulnerability of women to eating disorders relates to the fact that women’s brains are much more sensitive to dietary intake of tryptophan than are men’s brains,” explained Allan S. Kaplan, MD, senior scientist at the Center for Addiction and Mental Health at the University of Toronto.
“Women are more likely than men to be dieting,” said Dr. Kaplan, walking through the evidence. “Low-calorie diets tend to be high in protein and low in cholesterol and fat. Such diets lead to tryptophan depletion and decreased serotonin synthesis in the brain. Because of lower levels of central serotonin, women are more vulnerable to mood and eating disorders than men.”
Not all women who diet may be vulnerable to this sequence of events. Genetics are likely to be a factor, according to Dr. Kaplan, who said, “Genes load the gun; the environment pulls the trigger.”
However, women do appear to be more susceptible for a number of reasons. For one, the mean rate of serotonin synthesis is 52% higher in normal males than normal females, giving them a greater buffer when dietary intake of tryptophan is low. For another, there is evidence that intake of nutrients most rich in tryptophan, particularly proteins, is typically lower in women than men.
The ratio of females to males for both anorexia nervosa and bulimia nervosa is about 10:1. Although the female-to-male ratio of binge eating is lower at 2:1, women dominate these psychiatric diagnoses. Several environmental factors associated with eating disorders are more closely associated with women than men, including a history of sexual or physical abuse and female preoccupation with body image, but acute tryptophan depletion may be an important factor participating in the translation of risk to an active disease, according to Dr. Kaplan.
Acute tryptophan deficiency may also explain why treatment of eating disorders with SSRIs has been disappointing. With low levels of tryptophan leading to serotonin depletion, “there is no substrate” for drugs administered to increase serotonin-mediated signaling, Dr. Kaplan explained.
Ensuring adequate dietary intake of tryptophan, which is “found mainly in high-protein animal foods,” may be important, even though Dr. Kaplan warned that achieving optimal levels of serotonin “can be challenging from food alone.” Nevertheless, behavioral therapies are commonly effective for eating disorders, presumably at least partially as a result of their ability to normalize diet.
Overall, the tryptophan hypothesis has provided a major shift in the understanding of eating disorders, according to Dr. Kaplan. Further studies are needed, but he said that the key message is that, “For women’s brains, you are what you eat.”
Dr. Kaplan reported no conflicts of interest relevant to this topic.
This story was updated on 2/25/2018.
EXPERT ANALYSIS FROM THE COLLEGE 2018
For women with alcohol SUD, try gender-specific treatment
TAMPA – The distinct features of substance use disorders (SUDs) in women argue for gender-specific treatment, according to a comprehensive update presented at the annual meeting of the American College of Psychiatrists.
“There is a shorter time between landmarks of SUD progression, and these landmarks are reached at lower doses of alcohol consumed less frequently,” reported Shelly F. Greenfield, MD, chief academic officer at McLean Hospital in Boston.
“For each ounce of alcohol consumed, the blood alcohol concentration is higher with a greater potential for adverse physical consequences,” Dr. Greenfield said. These physiologic differences may account for the more rapid progression of SUD severity in women, a phenomenon that Dr. Greenfield referred to as “telescoping.” She said the same type of telescoping, defined as “an accelerated progression from the initiation of substance use to the onset of dependence and first admission to treatment” (Psychiatr Clin North Am. 2011 Jun 28;33[2]:339-55), also has been seen among women for opioids and stimulants (Drug Alcohol Depend. 2004 Jun 11;74[3]:265-72). These greater risks are reflected in a higher SUD-associated mortality in females, compared with SUD-associated mortality in males.
Relative rates of alcohol SUD among women have been climbing steadily for more than 30 years. In the 1980s, for example, a population survey estimated the male-to-female prevalence ratio of alcohol SUD as 5:1. Citing subsequent surveys, Dr. Greenfield traced a rapid narrowing of the gender gap. In one of the most recent surveys, the rate had fallen below 2:1. Rates of heaving drinking and binge drinking are now about 1.4:1 in individuals aged 18-25 years.
“Each time we look at this gap, it has narrowed further,” Dr. Greenfield said. In another survey she cited, illicit drug use among adolescents between ages 12 and 17 years was higher in boys, but alcohol use in males and females was essentially the same.
Several facts suggest that treatment specific to women will improve outcomes. For one, For another, women are more likely to have co-occurring psychiatric disorders. In one study, anxiety (60.7% vs. 35.8%) and mood disorders (53.5% vs. 28.1%) were nearly twice as common in women with SUDs than in their male counterparts. This is relevant to interventions tailored for females because of evidence showing that treatment for SUDs and co-occurring psychiatric disorders should be integrated rather than addressed independently, according to Dr. Greenfield.
Importantly, “there is evidence of improved treatment outcome in women-focused programs,” Dr. Greenfield said. She suggested that successful programs for alcohol SUD in women not only address gender-specific features but that success can be enhanced further with adjunctive services that address the barriers to treatment, such as child care challenges and stigma – which Dr. Greenfield said is greater in women than in men.
A study called the Women’s Recovery Group (WRG), funded by the National Institute on Drug Abuse and led by Dr. Greenfield, is among those that have reinforced the value of female-specific therapy for SUD (Drug Alcohol Depend. 2014 Sep 1;142:245-53). A manual developed from the study and published in a book she wrote called “Treating Women With Substance Use Disorders: The Women’s Recovery Group Manual” (New York: The Guilford Press, 2016), outlines the principles. Dr. Greenfield said the structured 12-session group therapy for relapse prevention has been effective and well received by women. Some of those women have commented on the reinforcing value of shared experiences.
Up until now, women with alcohol SUD have been commonly treated alongside men, but Dr. Greenfield contended that treatment outcomes with alcohol SUD or other forms of SUDs “can be enhanced by programs that provide services specific to women’s needs.” She believes strategies aimed at addressing the more common histories of sexual or physical trauma and psychiatric comorbidities along with gender-related barriers to treatment have the potential to increase treatment success.
In addition to writing “Treating Women With Substance Use Disorders,” Dr. Greenfield is a coeditor of “Women and Addiction: A Comprehensive Handbook” (New York: Guilford, 2009). She reported no conflicts of interest.
TAMPA – The distinct features of substance use disorders (SUDs) in women argue for gender-specific treatment, according to a comprehensive update presented at the annual meeting of the American College of Psychiatrists.
“There is a shorter time between landmarks of SUD progression, and these landmarks are reached at lower doses of alcohol consumed less frequently,” reported Shelly F. Greenfield, MD, chief academic officer at McLean Hospital in Boston.
“For each ounce of alcohol consumed, the blood alcohol concentration is higher with a greater potential for adverse physical consequences,” Dr. Greenfield said. These physiologic differences may account for the more rapid progression of SUD severity in women, a phenomenon that Dr. Greenfield referred to as “telescoping.” She said the same type of telescoping, defined as “an accelerated progression from the initiation of substance use to the onset of dependence and first admission to treatment” (Psychiatr Clin North Am. 2011 Jun 28;33[2]:339-55), also has been seen among women for opioids and stimulants (Drug Alcohol Depend. 2004 Jun 11;74[3]:265-72). These greater risks are reflected in a higher SUD-associated mortality in females, compared with SUD-associated mortality in males.
Relative rates of alcohol SUD among women have been climbing steadily for more than 30 years. In the 1980s, for example, a population survey estimated the male-to-female prevalence ratio of alcohol SUD as 5:1. Citing subsequent surveys, Dr. Greenfield traced a rapid narrowing of the gender gap. In one of the most recent surveys, the rate had fallen below 2:1. Rates of heaving drinking and binge drinking are now about 1.4:1 in individuals aged 18-25 years.
“Each time we look at this gap, it has narrowed further,” Dr. Greenfield said. In another survey she cited, illicit drug use among adolescents between ages 12 and 17 years was higher in boys, but alcohol use in males and females was essentially the same.
Several facts suggest that treatment specific to women will improve outcomes. For one, For another, women are more likely to have co-occurring psychiatric disorders. In one study, anxiety (60.7% vs. 35.8%) and mood disorders (53.5% vs. 28.1%) were nearly twice as common in women with SUDs than in their male counterparts. This is relevant to interventions tailored for females because of evidence showing that treatment for SUDs and co-occurring psychiatric disorders should be integrated rather than addressed independently, according to Dr. Greenfield.
Importantly, “there is evidence of improved treatment outcome in women-focused programs,” Dr. Greenfield said. She suggested that successful programs for alcohol SUD in women not only address gender-specific features but that success can be enhanced further with adjunctive services that address the barriers to treatment, such as child care challenges and stigma – which Dr. Greenfield said is greater in women than in men.
A study called the Women’s Recovery Group (WRG), funded by the National Institute on Drug Abuse and led by Dr. Greenfield, is among those that have reinforced the value of female-specific therapy for SUD (Drug Alcohol Depend. 2014 Sep 1;142:245-53). A manual developed from the study and published in a book she wrote called “Treating Women With Substance Use Disorders: The Women’s Recovery Group Manual” (New York: The Guilford Press, 2016), outlines the principles. Dr. Greenfield said the structured 12-session group therapy for relapse prevention has been effective and well received by women. Some of those women have commented on the reinforcing value of shared experiences.
Up until now, women with alcohol SUD have been commonly treated alongside men, but Dr. Greenfield contended that treatment outcomes with alcohol SUD or other forms of SUDs “can be enhanced by programs that provide services specific to women’s needs.” She believes strategies aimed at addressing the more common histories of sexual or physical trauma and psychiatric comorbidities along with gender-related barriers to treatment have the potential to increase treatment success.
In addition to writing “Treating Women With Substance Use Disorders,” Dr. Greenfield is a coeditor of “Women and Addiction: A Comprehensive Handbook” (New York: Guilford, 2009). She reported no conflicts of interest.
TAMPA – The distinct features of substance use disorders (SUDs) in women argue for gender-specific treatment, according to a comprehensive update presented at the annual meeting of the American College of Psychiatrists.
“There is a shorter time between landmarks of SUD progression, and these landmarks are reached at lower doses of alcohol consumed less frequently,” reported Shelly F. Greenfield, MD, chief academic officer at McLean Hospital in Boston.
“For each ounce of alcohol consumed, the blood alcohol concentration is higher with a greater potential for adverse physical consequences,” Dr. Greenfield said. These physiologic differences may account for the more rapid progression of SUD severity in women, a phenomenon that Dr. Greenfield referred to as “telescoping.” She said the same type of telescoping, defined as “an accelerated progression from the initiation of substance use to the onset of dependence and first admission to treatment” (Psychiatr Clin North Am. 2011 Jun 28;33[2]:339-55), also has been seen among women for opioids and stimulants (Drug Alcohol Depend. 2004 Jun 11;74[3]:265-72). These greater risks are reflected in a higher SUD-associated mortality in females, compared with SUD-associated mortality in males.
Relative rates of alcohol SUD among women have been climbing steadily for more than 30 years. In the 1980s, for example, a population survey estimated the male-to-female prevalence ratio of alcohol SUD as 5:1. Citing subsequent surveys, Dr. Greenfield traced a rapid narrowing of the gender gap. In one of the most recent surveys, the rate had fallen below 2:1. Rates of heaving drinking and binge drinking are now about 1.4:1 in individuals aged 18-25 years.
“Each time we look at this gap, it has narrowed further,” Dr. Greenfield said. In another survey she cited, illicit drug use among adolescents between ages 12 and 17 years was higher in boys, but alcohol use in males and females was essentially the same.
Several facts suggest that treatment specific to women will improve outcomes. For one, For another, women are more likely to have co-occurring psychiatric disorders. In one study, anxiety (60.7% vs. 35.8%) and mood disorders (53.5% vs. 28.1%) were nearly twice as common in women with SUDs than in their male counterparts. This is relevant to interventions tailored for females because of evidence showing that treatment for SUDs and co-occurring psychiatric disorders should be integrated rather than addressed independently, according to Dr. Greenfield.
Importantly, “there is evidence of improved treatment outcome in women-focused programs,” Dr. Greenfield said. She suggested that successful programs for alcohol SUD in women not only address gender-specific features but that success can be enhanced further with adjunctive services that address the barriers to treatment, such as child care challenges and stigma – which Dr. Greenfield said is greater in women than in men.
A study called the Women’s Recovery Group (WRG), funded by the National Institute on Drug Abuse and led by Dr. Greenfield, is among those that have reinforced the value of female-specific therapy for SUD (Drug Alcohol Depend. 2014 Sep 1;142:245-53). A manual developed from the study and published in a book she wrote called “Treating Women With Substance Use Disorders: The Women’s Recovery Group Manual” (New York: The Guilford Press, 2016), outlines the principles. Dr. Greenfield said the structured 12-session group therapy for relapse prevention has been effective and well received by women. Some of those women have commented on the reinforcing value of shared experiences.
Up until now, women with alcohol SUD have been commonly treated alongside men, but Dr. Greenfield contended that treatment outcomes with alcohol SUD or other forms of SUDs “can be enhanced by programs that provide services specific to women’s needs.” She believes strategies aimed at addressing the more common histories of sexual or physical trauma and psychiatric comorbidities along with gender-related barriers to treatment have the potential to increase treatment success.
In addition to writing “Treating Women With Substance Use Disorders,” Dr. Greenfield is a coeditor of “Women and Addiction: A Comprehensive Handbook” (New York: Guilford, 2009). She reported no conflicts of interest.
REPORTING FROM THE COLLEGE 2018