Residents' Voices

Near completion of my rounds at a residential substance abuse treatment center, my last patient was a 32-year-old mother. She reported she was there because her newborn had tested positive for cocaine. She stated, “I want to do better. I thought this pregnancy would change things, but it was so hard to stop.” Her admission made me reflect on a proposed bill in my state of Tennessee called the Fetal Assault Bill, which if put into law would affect women such as my patient and her newborn child.

The Tennessee Fetal Assault Bill was originally enacted in 2014, expired in 2016, and failed to pass in 2017. The bill was reintroduced for consideration in February 2019. If enacted, it would subject a woman to prosecution if her illegal use of a substance while pregnant causes her child to be born addicted to or harmed by that drug. However, the mother is protected from prosecution if she “enrolled in an addiction recovery program before the child is born, remained in the program after delivery, and successfully completed the program, regardless of whether the child was born addicted to or harmed by the narcotic drug.”¹ This bill is based on the premise that the unborn fetus has the same rights as a born child, and that the threat of incarceration will deter pregnant women from using illegal substances while pregnant.

Pregnant women may enroll in a drug treatment program prior to delivery to avoid prosecution; however, there is a paucity of addiction treatment centers available to pregnant women. Moreover, there is limited access in areas where babies are more likely to be born affected by the use of illegal substances. Few provisions have been made to address the additional barriers to treatment these women face, such as a lack of insurance or underinsurance for rehabilitation treatment, lack of transportation, and limited finances. Additional barriers include limited social supports, the need for childcare arrangements for existing children, and social stigma.

A 2017 report by Amnesty International regarding the original enactment of the Tennessee Fetal Assault Bill in 2014 noted some mothers who used illegal substances were afraid of prosecution.² This fear caused some to delay prenatal care or evade social services in order to prevent being reported. According to Amnesty International, laws such as the one proposed in Tennessee often show disparities in how they are implemented. Research shows that women of lower socioeconomic status and minorities tend to receive more frequent drug testing and harsher punishments.³

There are benefits to dedicating more resources to addiction treatment and other social services for pregnant women who use illegal substances. Reports show that mothers are motivated to stay abstinent in treatment centers where they are housed with their children. This model of treatment is more cost-effective than incarceration, which includes legal costs, prison costs, and foster care bills. Moreover, a possible felony charge may hinder a woman’s job opportunities and further compound her problems and those of her infant.

In the light of these benefits, instead of re-enacting the 2014 law, which did not yield any conclusive benefits for newborns or mothers who used illegal substances, alternatives should be attempted. Early identification of and interventions for women who are at risk for substance use while pregnant should be implemented. Practical, accessible support services will encourage sobriety, prevent fetal exposure to illegal substances, and improve child health outcomes. Research shows that substance abuse treatment during pregnancy reduces the risk of harm before birth and improves the quality of parental care after birth.⁴ Legislators and clinicians should emphasize improving access to treatment, expanding integrative addiction treatment centers, and encouraging self-reporting early in pregnancy. This goal cannot be achieved with an emphasis on incarcerating mothers.

Near completion of my rounds at a residential substance abuse treatment center, my last patient was a 32-year-old mother. She reported she was there because her newborn had tested positive for cocaine. She stated, “I want to do better. I thought this pregnancy would change things, but it was so hard to stop.” Her admission made me reflect on a proposed bill in my state of Tennessee called the Fetal Assault Bill, which if put into law would affect women such as my patient and her newborn child.

The Tennessee Fetal Assault Bill was originally enacted in 2014, expired in 2016, and failed to pass in 2017. The bill was reintroduced for consideration in February 2019. If enacted, it would subject a woman to prosecution if her illegal use of a substance while pregnant causes her child to be born addicted to or harmed by that drug. However, the mother is protected from prosecution if she “enrolled in an addiction recovery program before the child is born, remained in the program after delivery, and successfully completed the program, regardless of whether the child was born addicted to or harmed by the narcotic drug.”¹ This bill is based on the premise that the unborn fetus has the same rights as a born child, and that the threat of incarceration will deter pregnant women from using illegal substances while pregnant.

Pregnant women may enroll in a drug treatment program prior to delivery to avoid prosecution; however, there is a paucity of addiction treatment centers available to pregnant women. Moreover, there is limited access in areas where babies are more likely to be born affected by the use of illegal substances. Few provisions have been made to address the additional barriers to treatment these women face, such as a lack of insurance or underinsurance for rehabilitation treatment, lack of transportation, and limited finances. Additional barriers include limited social supports, the need for childcare arrangements for existing children, and social stigma.

A 2017 report by Amnesty International regarding the original enactment of the Tennessee Fetal Assault Bill in 2014 noted some mothers who used illegal substances were afraid of prosecution.² This fear caused some to delay prenatal care or evade social services in order to prevent being reported. According to Amnesty International, laws such as the one proposed in Tennessee often show disparities in how they are implemented. Research shows that women of lower socioeconomic status and minorities tend to receive more frequent drug testing and harsher punishments.³

There are benefits to dedicating more resources to addiction treatment and other social services for pregnant women who use illegal substances. Reports show that mothers are motivated to stay abstinent in treatment centers where they are housed with their children. This model of treatment is more cost-effective than incarceration, which includes legal costs, prison costs, and foster care bills. Moreover, a possible felony charge may hinder a woman’s job opportunities and further compound her problems and those of her infant.

In the light of these benefits, instead of re-enacting the 2014 law, which did not yield any conclusive benefits for newborns or mothers who used illegal substances, alternatives should be attempted. Early identification of and interventions for women who are at risk for substance use while pregnant should be implemented. Practical, accessible support services will encourage sobriety, prevent fetal exposure to illegal substances, and improve child health outcomes. Research shows that substance abuse treatment during pregnancy reduces the risk of harm before birth and improves the quality of parental care after birth.⁴ Legislators and clinicians should emphasize improving access to treatment, expanding integrative addiction treatment centers, and encouraging self-reporting early in pregnancy. This goal cannot be achieved with an emphasis on incarcerating mothers.

Near completion of my rounds at a residential substance abuse treatment center, my last patient was a 32-year-old mother. She reported she was there because her newborn had tested positive for cocaine. She stated, “I want to do better. I thought this pregnancy would change things, but it was so hard to stop.” Her admission made me reflect on a proposed bill in my state of Tennessee called the Fetal Assault Bill, which if put into law would affect women such as my patient and her newborn child.

The Tennessee Fetal Assault Bill was originally enacted in 2014, expired in 2016, and failed to pass in 2017. The bill was reintroduced for consideration in February 2019. If enacted, it would subject a woman to prosecution if her illegal use of a substance while pregnant causes her child to be born addicted to or harmed by that drug. However, the mother is protected from prosecution if she “enrolled in an addiction recovery program before the child is born, remained in the program after delivery, and successfully completed the program, regardless of whether the child was born addicted to or harmed by the narcotic drug.”¹ This bill is based on the premise that the unborn fetus has the same rights as a born child, and that the threat of incarceration will deter pregnant women from using illegal substances while pregnant.

Pregnant women may enroll in a drug treatment program prior to delivery to avoid prosecution; however, there is a paucity of addiction treatment centers available to pregnant women. Moreover, there is limited access in areas where babies are more likely to be born affected by the use of illegal substances. Few provisions have been made to address the additional barriers to treatment these women face, such as a lack of insurance or underinsurance for rehabilitation treatment, lack of transportation, and limited finances. Additional barriers include limited social supports, the need for childcare arrangements for existing children, and social stigma.

A 2017 report by Amnesty International regarding the original enactment of the Tennessee Fetal Assault Bill in 2014 noted some mothers who used illegal substances were afraid of prosecution.² This fear caused some to delay prenatal care or evade social services in order to prevent being reported. According to Amnesty International, laws such as the one proposed in Tennessee often show disparities in how they are implemented. Research shows that women of lower socioeconomic status and minorities tend to receive more frequent drug testing and harsher punishments.³

There are benefits to dedicating more resources to addiction treatment and other social services for pregnant women who use illegal substances. Reports show that mothers are motivated to stay abstinent in treatment centers where they are housed with their children. This model of treatment is more cost-effective than incarceration, which includes legal costs, prison costs, and foster care bills. Moreover, a possible felony charge may hinder a woman’s job opportunities and further compound her problems and those of her infant.

In the light of these benefits, instead of re-enacting the 2014 law, which did not yield any conclusive benefits for newborns or mothers who used illegal substances, alternatives should be attempted. Early identification of and interventions for women who are at risk for substance use while pregnant should be implemented. Practical, accessible support services will encourage sobriety, prevent fetal exposure to illegal substances, and improve child health outcomes. Research shows that substance abuse treatment during pregnancy reduces the risk of harm before birth and improves the quality of parental care after birth.⁴ Legislators and clinicians should emphasize improving access to treatment, expanding integrative addiction treatment centers, and encouraging self-reporting early in pregnancy. This goal cannot be achieved with an emphasis on incarcerating mothers.

“A leader is someone who helps improve the lives of other people or improve the system they live under.”

— Sam Houston

If my motivation to become a doctor was ever the supposed glamour and prestige conferred once “MD” is added to your name, that delusion was quickly wiped away on my first day of residency; not at work, but on my way there.

I live in New York City—a city that relies on buses and subways, where the wealthy and elite go to work using the same modes of transportation as everyone else. Unfortunately, because the shelter system in New York isn’t nearly large enough to accommodate the vast homeless population, many homeless people sleep in the subway at night. It’s not uncommon to see a still-sleeping homeless person on the subway in the early hours of the morning, and I encountered one on my first official day of work as a doctor.

There I was, dressed for the occasion in a new, freshly ironed white button-down shirt and black slacks. There he was, haggard, disheveled, and smelling of alcohol, lying on a subway bench with an empty bottle of vodka tucked into his pants pocket. Out of both pity and fear of what he might do if someone attempted to wake him, people allowed him to sleep, and politely stood around him as the train proceeded on its route. The homeless man had his legs tucked in the fetal position, and I saw there was enough space on the bench for someone to sit. I wondered why nobody else chose to use that space by his feet, and I saw no harm in sitting there, so I did.

Within seconds of sitting down, the man extended one of his legs and kicked me in the chest while still asleep. Not hard enough to cause pain or injury, but enough to leave a dirty boot print on my shirt. I had to wear that shirt for the rest of the day, and so I spent my first day of residency explaining to hospital staff and patients alike how I was branded by a drunk homeless man on the subway as he slept.

As time wore on in my first year of residency, I learned that encounters with individuals like these were not rare. The majority of the patients I see are people like that man on the subway. “I sleep on the subway” is often the answer when I ask a patient about their living conditions. “I’m on public assistance” is what I hear when questioning what a patient does for money. “I don’t have money to take the bus” is a typical explanation for why they missed their doctor’s appointments and ran out of medicine. And, sadly, “Because I’m lonely” is the main excuse for why patients engage in self-defeating habits such as drug and alcohol abuse.

I didn’t anticipate this part of psychiatry when I applied for residency in this specialty. My notion of this profession was far more romanticized. I was enthralled with the science of neurotransmitters, the parameters of DSM criteria, the interpersonal skills required to elicit information from a patient during an interview, the deliberation in arriving at a diagnosis, and the ever-changing nature of psychopharmacology. That’s the psychiatry I expected to learn when I got on the subway for my first day of residency. It wasn’t until later that I truly considered the human toll that psychiatric illness takes on the individual who suffers from it. To that person, the science behind their illness and the suffering they endure isn’t romantic at all; it’s a burden to be lifted.

Continue to: We use the term...

We use the term “underserved” to identify challenging patient populations, but there are categories of patients that fall below the threshold of merely underserved. I am mortified to know that one-third of homeless people in the United States have a serious and untreated mental illness. Individuals discharged from psychiatric hospitals are 3 times more likely to obtain food from garbage. They are also far more likely to be the victim of a crime than perpetrators of it. As I’ve discovered since starting residency, if a patient doesn’t have a place to live, food to eat, and some semblance of a support system, then it’s often meaningless for them to take pills, regardless of how those pills work in theory.

No definition of sound mental health is complete unless it gives deference to those who lack basic human needs. This is a realization that was literally kicked into me, and one I hope will guide me in the years ahead.

“A leader is someone who helps improve the lives of other people or improve the system they live under.”

— Sam Houston

If my motivation to become a doctor was ever the supposed glamour and prestige conferred once “MD” is added to your name, that delusion was quickly wiped away on my first day of residency; not at work, but on my way there.

I live in New York City—a city that relies on buses and subways, where the wealthy and elite go to work using the same modes of transportation as everyone else. Unfortunately, because the shelter system in New York isn’t nearly large enough to accommodate the vast homeless population, many homeless people sleep in the subway at night. It’s not uncommon to see a still-sleeping homeless person on the subway in the early hours of the morning, and I encountered one on my first official day of work as a doctor.

There I was, dressed for the occasion in a new, freshly ironed white button-down shirt and black slacks. There he was, haggard, disheveled, and smelling of alcohol, lying on a subway bench with an empty bottle of vodka tucked into his pants pocket. Out of both pity and fear of what he might do if someone attempted to wake him, people allowed him to sleep, and politely stood around him as the train proceeded on its route. The homeless man had his legs tucked in the fetal position, and I saw there was enough space on the bench for someone to sit. I wondered why nobody else chose to use that space by his feet, and I saw no harm in sitting there, so I did.

Within seconds of sitting down, the man extended one of his legs and kicked me in the chest while still asleep. Not hard enough to cause pain or injury, but enough to leave a dirty boot print on my shirt. I had to wear that shirt for the rest of the day, and so I spent my first day of residency explaining to hospital staff and patients alike how I was branded by a drunk homeless man on the subway as he slept.

As time wore on in my first year of residency, I learned that encounters with individuals like these were not rare. The majority of the patients I see are people like that man on the subway. “I sleep on the subway” is often the answer when I ask a patient about their living conditions. “I’m on public assistance” is what I hear when questioning what a patient does for money. “I don’t have money to take the bus” is a typical explanation for why they missed their doctor’s appointments and ran out of medicine. And, sadly, “Because I’m lonely” is the main excuse for why patients engage in self-defeating habits such as drug and alcohol abuse.

I didn’t anticipate this part of psychiatry when I applied for residency in this specialty. My notion of this profession was far more romanticized. I was enthralled with the science of neurotransmitters, the parameters of DSM criteria, the interpersonal skills required to elicit information from a patient during an interview, the deliberation in arriving at a diagnosis, and the ever-changing nature of psychopharmacology. That’s the psychiatry I expected to learn when I got on the subway for my first day of residency. It wasn’t until later that I truly considered the human toll that psychiatric illness takes on the individual who suffers from it. To that person, the science behind their illness and the suffering they endure isn’t romantic at all; it’s a burden to be lifted.

Continue to: We use the term...

We use the term “underserved” to identify challenging patient populations, but there are categories of patients that fall below the threshold of merely underserved. I am mortified to know that one-third of homeless people in the United States have a serious and untreated mental illness. Individuals discharged from psychiatric hospitals are 3 times more likely to obtain food from garbage. They are also far more likely to be the victim of a crime than perpetrators of it. As I’ve discovered since starting residency, if a patient doesn’t have a place to live, food to eat, and some semblance of a support system, then it’s often meaningless for them to take pills, regardless of how those pills work in theory.

No definition of sound mental health is complete unless it gives deference to those who lack basic human needs. This is a realization that was literally kicked into me, and one I hope will guide me in the years ahead.

“A leader is someone who helps improve the lives of other people or improve the system they live under.”

— Sam Houston

If my motivation to become a doctor was ever the supposed glamour and prestige conferred once “MD” is added to your name, that delusion was quickly wiped away on my first day of residency; not at work, but on my way there.

I live in New York City—a city that relies on buses and subways, where the wealthy and elite go to work using the same modes of transportation as everyone else. Unfortunately, because the shelter system in New York isn’t nearly large enough to accommodate the vast homeless population, many homeless people sleep in the subway at night. It’s not uncommon to see a still-sleeping homeless person on the subway in the early hours of the morning, and I encountered one on my first official day of work as a doctor.

There I was, dressed for the occasion in a new, freshly ironed white button-down shirt and black slacks. There he was, haggard, disheveled, and smelling of alcohol, lying on a subway bench with an empty bottle of vodka tucked into his pants pocket. Out of both pity and fear of what he might do if someone attempted to wake him, people allowed him to sleep, and politely stood around him as the train proceeded on its route. The homeless man had his legs tucked in the fetal position, and I saw there was enough space on the bench for someone to sit. I wondered why nobody else chose to use that space by his feet, and I saw no harm in sitting there, so I did.

Within seconds of sitting down, the man extended one of his legs and kicked me in the chest while still asleep. Not hard enough to cause pain or injury, but enough to leave a dirty boot print on my shirt. I had to wear that shirt for the rest of the day, and so I spent my first day of residency explaining to hospital staff and patients alike how I was branded by a drunk homeless man on the subway as he slept.

As time wore on in my first year of residency, I learned that encounters with individuals like these were not rare. The majority of the patients I see are people like that man on the subway. “I sleep on the subway” is often the answer when I ask a patient about their living conditions. “I’m on public assistance” is what I hear when questioning what a patient does for money. “I don’t have money to take the bus” is a typical explanation for why they missed their doctor’s appointments and ran out of medicine. And, sadly, “Because I’m lonely” is the main excuse for why patients engage in self-defeating habits such as drug and alcohol abuse.

I didn’t anticipate this part of psychiatry when I applied for residency in this specialty. My notion of this profession was far more romanticized. I was enthralled with the science of neurotransmitters, the parameters of DSM criteria, the interpersonal skills required to elicit information from a patient during an interview, the deliberation in arriving at a diagnosis, and the ever-changing nature of psychopharmacology. That’s the psychiatry I expected to learn when I got on the subway for my first day of residency. It wasn’t until later that I truly considered the human toll that psychiatric illness takes on the individual who suffers from it. To that person, the science behind their illness and the suffering they endure isn’t romantic at all; it’s a burden to be lifted.

Continue to: We use the term...

We use the term “underserved” to identify challenging patient populations, but there are categories of patients that fall below the threshold of merely underserved. I am mortified to know that one-third of homeless people in the United States have a serious and untreated mental illness. Individuals discharged from psychiatric hospitals are 3 times more likely to obtain food from garbage. They are also far more likely to be the victim of a crime than perpetrators of it. As I’ve discovered since starting residency, if a patient doesn’t have a place to live, food to eat, and some semblance of a support system, then it’s often meaningless for them to take pills, regardless of how those pills work in theory.

No definition of sound mental health is complete unless it gives deference to those who lack basic human needs. This is a realization that was literally kicked into me, and one I hope will guide me in the years ahead.

Editor’s note:  Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.

In this Career Choices, Saeed Ahmed, MD, Chief Resident at Nassau University Medical Center, East Meadow, New York, talked with Donald W. Black, MD, Professor of Psychiatry, Department of Psychiatry, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa. Dr. Black is also Editor-in-Chief of Annals of Clinical Psychiatry, and Secretary/Treasurer and former President of the American Academy of Clinical Psychiatrists. He is a clinical and translational researcher with more than 300 publications. His work has focused on the course and treatment of severe personality disorders, including researching the effectiveness of the Systems Training for Emotional Predictability and Problem Solving (STEPPS) program for borderline personality disorder. He also conducts family and follow-up studies of behavioral addictions, including gambling disorder.

Dr. Ahmed: What made you choose the academic track, and how did your training lead you towards this path?

Dr. Black: I had always been interested in the idea of working at a medical school, and enjoyed writing and speaking. I was exposed to clinical research as a resident, and that confirmed my interest in academia, because I could envision combining all my interests, along with patient care. I always thought that patients were a major source of ideas for research and writing.

Dr. Ahmed: What are some of the pros and cons of working in academia?

Dr. Black: The pros include being able to influence future physicians through my teaching and writing; being able to pursue important research; and not being isolated from peers. Other advantages are being largely protected from utilization review; having more free time than peers in the private sector, who have difficulty finding coverage; and having defined benefits and a steady salary. I also share call with many peers.

When it comes to the cons, salaries are lower than in the private sector. The cons also include not being my own boss, and sometimes having to bend to the whims of an institution or supervisor.

Continue to: Dr. Ahmed...

Dr. Ahmed: Are you required to conduct research?

Dr. Black: Yes. This is one of the best aspects of my job: being able to make clinical discoveries that I can disseminate through writing and speaking. Over time, this has become increasingly challenging due to the difficulty of obtaining research funding from foundations or the federal government. This has become highly problematic, particularly for clinical researchers, because the National Institutes of Health has clearly been favoring neuroscience.

Dr. Ahmed: What is your typical day like?

Dr. Black: Because of the many hats I wear (or have worn), each day is different from the other. I combine patient care with research, writing, speaking, teaching, and administration. As a tenure-track faculty member, I am expected to write grants, conduct research, and publish. My clinical-track peers primarily provide patient care and teach students and residents.

Dr. Ahmed: What is unique about working in a training institute vs private practice?

Continue to: Dr. Black...

Dr. Black: As an academic psychiatrist, I feel I have the best of both worlds: patient care combined with opportunities my private practice colleagues do not have. Because I have published widely, and have developed a reputation, I am frequently invited to speak at meetings throughout the United States, and sometimes internationally. Travel is a perk of academia, and as someone who loves travel, that is important.

Dr. Ahmed: Where do you see psychiatry going?

Dr. Black: Psychiatry will always be an important specialty because no one else truly cares about patients with psychiatric illnesses. Mental illness will not go away, and society needs highly trained individuals to provide care. There are many “me too” clinicians who now share in caring for patients with psychiatric illnesses, but psychiatrists will always have the most training, and are in a position to provide supervision to others and to direct mental health care teams.

Dr. Ahmed: What advice do you have for residents contemplating a career in academic psychiatry?

Dr. Black: Because most medical schools now have both tenure and clinical tracks, no one needs to feel left out. Those who are interested in scholarly activities will gravitate to the tenure tract, and all that requires in terms of grants and papers, while those who are primarily interested in patient care and teaching will choose the clinical track.

Editor’s note:  Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.

In this Career Choices, Saeed Ahmed, MD, Chief Resident at Nassau University Medical Center, East Meadow, New York, talked with Donald W. Black, MD, Professor of Psychiatry, Department of Psychiatry, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa. Dr. Black is also Editor-in-Chief of Annals of Clinical Psychiatry, and Secretary/Treasurer and former President of the American Academy of Clinical Psychiatrists. He is a clinical and translational researcher with more than 300 publications. His work has focused on the course and treatment of severe personality disorders, including researching the effectiveness of the Systems Training for Emotional Predictability and Problem Solving (STEPPS) program for borderline personality disorder. He also conducts family and follow-up studies of behavioral addictions, including gambling disorder.

Dr. Ahmed: What made you choose the academic track, and how did your training lead you towards this path?

Dr. Black: I had always been interested in the idea of working at a medical school, and enjoyed writing and speaking. I was exposed to clinical research as a resident, and that confirmed my interest in academia, because I could envision combining all my interests, along with patient care. I always thought that patients were a major source of ideas for research and writing.

Dr. Ahmed: What are some of the pros and cons of working in academia?

Dr. Black: The pros include being able to influence future physicians through my teaching and writing; being able to pursue important research; and not being isolated from peers. Other advantages are being largely protected from utilization review; having more free time than peers in the private sector, who have difficulty finding coverage; and having defined benefits and a steady salary. I also share call with many peers.

When it comes to the cons, salaries are lower than in the private sector. The cons also include not being my own boss, and sometimes having to bend to the whims of an institution or supervisor.

Continue to: Dr. Ahmed...

Dr. Ahmed: Are you required to conduct research?

Dr. Black: Yes. This is one of the best aspects of my job: being able to make clinical discoveries that I can disseminate through writing and speaking. Over time, this has become increasingly challenging due to the difficulty of obtaining research funding from foundations or the federal government. This has become highly problematic, particularly for clinical researchers, because the National Institutes of Health has clearly been favoring neuroscience.

Dr. Ahmed: What is your typical day like?

Dr. Black: Because of the many hats I wear (or have worn), each day is different from the other. I combine patient care with research, writing, speaking, teaching, and administration. As a tenure-track faculty member, I am expected to write grants, conduct research, and publish. My clinical-track peers primarily provide patient care and teach students and residents.

Dr. Ahmed: What is unique about working in a training institute vs private practice?

Continue to: Dr. Black...

Dr. Black: As an academic psychiatrist, I feel I have the best of both worlds: patient care combined with opportunities my private practice colleagues do not have. Because I have published widely, and have developed a reputation, I am frequently invited to speak at meetings throughout the United States, and sometimes internationally. Travel is a perk of academia, and as someone who loves travel, that is important.

Dr. Ahmed: Where do you see psychiatry going?

Dr. Black: Psychiatry will always be an important specialty because no one else truly cares about patients with psychiatric illnesses. Mental illness will not go away, and society needs highly trained individuals to provide care. There are many “me too” clinicians who now share in caring for patients with psychiatric illnesses, but psychiatrists will always have the most training, and are in a position to provide supervision to others and to direct mental health care teams.

Dr. Ahmed: What advice do you have for residents contemplating a career in academic psychiatry?

Dr. Black: Because most medical schools now have both tenure and clinical tracks, no one needs to feel left out. Those who are interested in scholarly activities will gravitate to the tenure tract, and all that requires in terms of grants and papers, while those who are primarily interested in patient care and teaching will choose the clinical track.

Editor’s note:  Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.

In this Career Choices, Saeed Ahmed, MD, Chief Resident at Nassau University Medical Center, East Meadow, New York, talked with Donald W. Black, MD, Professor of Psychiatry, Department of Psychiatry, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa. Dr. Black is also Editor-in-Chief of Annals of Clinical Psychiatry, and Secretary/Treasurer and former President of the American Academy of Clinical Psychiatrists. He is a clinical and translational researcher with more than 300 publications. His work has focused on the course and treatment of severe personality disorders, including researching the effectiveness of the Systems Training for Emotional Predictability and Problem Solving (STEPPS) program for borderline personality disorder. He also conducts family and follow-up studies of behavioral addictions, including gambling disorder.

Dr. Ahmed: What made you choose the academic track, and how did your training lead you towards this path?

Dr. Black: I had always been interested in the idea of working at a medical school, and enjoyed writing and speaking. I was exposed to clinical research as a resident, and that confirmed my interest in academia, because I could envision combining all my interests, along with patient care. I always thought that patients were a major source of ideas for research and writing.

Dr. Ahmed: What are some of the pros and cons of working in academia?

Dr. Black: The pros include being able to influence future physicians through my teaching and writing; being able to pursue important research; and not being isolated from peers. Other advantages are being largely protected from utilization review; having more free time than peers in the private sector, who have difficulty finding coverage; and having defined benefits and a steady salary. I also share call with many peers.

When it comes to the cons, salaries are lower than in the private sector. The cons also include not being my own boss, and sometimes having to bend to the whims of an institution or supervisor.

Continue to: Dr. Ahmed...

Dr. Ahmed: Are you required to conduct research?

Dr. Black: Yes. This is one of the best aspects of my job: being able to make clinical discoveries that I can disseminate through writing and speaking. Over time, this has become increasingly challenging due to the difficulty of obtaining research funding from foundations or the federal government. This has become highly problematic, particularly for clinical researchers, because the National Institutes of Health has clearly been favoring neuroscience.

Dr. Ahmed: What is your typical day like?

Dr. Black: Because of the many hats I wear (or have worn), each day is different from the other. I combine patient care with research, writing, speaking, teaching, and administration. As a tenure-track faculty member, I am expected to write grants, conduct research, and publish. My clinical-track peers primarily provide patient care and teach students and residents.

Dr. Ahmed: What is unique about working in a training institute vs private practice?

Continue to: Dr. Black...

Dr. Black: As an academic psychiatrist, I feel I have the best of both worlds: patient care combined with opportunities my private practice colleagues do not have. Because I have published widely, and have developed a reputation, I am frequently invited to speak at meetings throughout the United States, and sometimes internationally. Travel is a perk of academia, and as someone who loves travel, that is important.

Dr. Ahmed: Where do you see psychiatry going?

Dr. Black: Psychiatry will always be an important specialty because no one else truly cares about patients with psychiatric illnesses. Mental illness will not go away, and society needs highly trained individuals to provide care. There are many “me too” clinicians who now share in caring for patients with psychiatric illnesses, but psychiatrists will always have the most training, and are in a position to provide supervision to others and to direct mental health care teams.

Dr. Ahmed: What advice do you have for residents contemplating a career in academic psychiatry?

Dr. Black: Because most medical schools now have both tenure and clinical tracks, no one needs to feel left out. Those who are interested in scholarly activities will gravitate to the tenure tract, and all that requires in terms of grants and papers, while those who are primarily interested in patient care and teaching will choose the clinical track.

“Hi Dr. Burke, thanks for coming in today. My daughter struggles with depression and I feel like every time I try to reach out, I hit a dead end with her. How do I connect with someone, who by the nature of their disease, is hard to reach?”

The answer? I’m not quite sure. I stood in front of a classroom of parents, siblings, and persons struggling with mental health issues, lecturing about depression. I can tell you about the complex interplay of biologic, psychological, and social factors that can lead one to become depressed. I can tell you the prevalence of depression in today’s society, and how it is rising among all age groups. I can tell you a myriad of different treatments, from pharmacologic to therapeutic to procedural, for depression. But how, from a parent’s perspective, can you connect with your child struggling with depression when they do not want your help? That I cannot tell you, at least not yet, anyways.

I had connected with the National Alliance on Mental Illness (NAMI) in the Fall of 2018, when a patient of mine was discharged from hospitalization and told by a faith-based substance use treatment program that he would not be allowed to use any “mind-altering” medications when he returned to their program. Concerned about my patient, whom I had just stabilized with the use of medications, I did my best to work through that organization’s resistance to psychotropic medications. When that failed, I reached out to NAMI for help in advocating for persons with mental illness. My involvement escalated to giving a lecture on “Living with Depression” to our local chapter of approximately 25 individuals that night. I had expected to lecture to an engaged crowd about what I thought was my immense knowledge of depression, from diagnosis to development to treatment. What I had not expected, however, was to have a learning experience of my own.

I stood at the front of the room, listening to story after story of persons with depression and their family members discussing their experiences. Throughout the 90-minute lecture, my emotions ranged from being impressed to shocked, scared, and, ultimately, proud. For the past year and 7 months, I had been spending time with persons with mental illness on what was likely the worst days of their lives. I had seen a variety of severe presentations, from grossly psychotic to acutely manic to majorly depressed to highly agitated. With that wealth of experience, I had thought I was becoming an expert; however, at the front of that classroom that night, I realized how little I actually knew. Yes, I had contemplated before how much severe mental illness and hospitalization could affect a person and their loved ones. However, it was a different level of understanding to hear first-hand accounts of the loss of relationships, the struggle to connect, and the fall-out from intensive inpatient treatment.

In residency, we spend what seems like an immeasurable amount of time on inpatient psychiatric units, in outpatient clinics, and everywhere in between. We see so many patients on a daily, weekly, monthly, and yearly basis that it becomes easy to lose the individuality of each patient. We start associating patients with their disorder, rather than with who they are. However, if we take a step back and allow a larger perspective—one that considers not only the patient but their families and communities—we likely would be able to provide greater and more comprehensive care.

My experience at NAMI was one that I will treasure forever. It opened my eyes to struggles that had I failed to even notice, and for that, and many other connections I made, I am grateful to have been blessed with this experience. My greatest recommendation to my fellow residents would be to engage with your local community organizations in the hope that you, too, can have an eye-opening experience that will strengthen your practice.

“Hi Dr. Burke, thanks for coming in today. My daughter struggles with depression and I feel like every time I try to reach out, I hit a dead end with her. How do I connect with someone, who by the nature of their disease, is hard to reach?”

The answer? I’m not quite sure. I stood in front of a classroom of parents, siblings, and persons struggling with mental health issues, lecturing about depression. I can tell you about the complex interplay of biologic, psychological, and social factors that can lead one to become depressed. I can tell you the prevalence of depression in today’s society, and how it is rising among all age groups. I can tell you a myriad of different treatments, from pharmacologic to therapeutic to procedural, for depression. But how, from a parent’s perspective, can you connect with your child struggling with depression when they do not want your help? That I cannot tell you, at least not yet, anyways.

I had connected with the National Alliance on Mental Illness (NAMI) in the Fall of 2018, when a patient of mine was discharged from hospitalization and told by a faith-based substance use treatment program that he would not be allowed to use any “mind-altering” medications when he returned to their program. Concerned about my patient, whom I had just stabilized with the use of medications, I did my best to work through that organization’s resistance to psychotropic medications. When that failed, I reached out to NAMI for help in advocating for persons with mental illness. My involvement escalated to giving a lecture on “Living with Depression” to our local chapter of approximately 25 individuals that night. I had expected to lecture to an engaged crowd about what I thought was my immense knowledge of depression, from diagnosis to development to treatment. What I had not expected, however, was to have a learning experience of my own.

I stood at the front of the room, listening to story after story of persons with depression and their family members discussing their experiences. Throughout the 90-minute lecture, my emotions ranged from being impressed to shocked, scared, and, ultimately, proud. For the past year and 7 months, I had been spending time with persons with mental illness on what was likely the worst days of their lives. I had seen a variety of severe presentations, from grossly psychotic to acutely manic to majorly depressed to highly agitated. With that wealth of experience, I had thought I was becoming an expert; however, at the front of that classroom that night, I realized how little I actually knew. Yes, I had contemplated before how much severe mental illness and hospitalization could affect a person and their loved ones. However, it was a different level of understanding to hear first-hand accounts of the loss of relationships, the struggle to connect, and the fall-out from intensive inpatient treatment.

In residency, we spend what seems like an immeasurable amount of time on inpatient psychiatric units, in outpatient clinics, and everywhere in between. We see so many patients on a daily, weekly, monthly, and yearly basis that it becomes easy to lose the individuality of each patient. We start associating patients with their disorder, rather than with who they are. However, if we take a step back and allow a larger perspective—one that considers not only the patient but their families and communities—we likely would be able to provide greater and more comprehensive care.

My experience at NAMI was one that I will treasure forever. It opened my eyes to struggles that had I failed to even notice, and for that, and many other connections I made, I am grateful to have been blessed with this experience. My greatest recommendation to my fellow residents would be to engage with your local community organizations in the hope that you, too, can have an eye-opening experience that will strengthen your practice.

“Hi Dr. Burke, thanks for coming in today. My daughter struggles with depression and I feel like every time I try to reach out, I hit a dead end with her. How do I connect with someone, who by the nature of their disease, is hard to reach?”

The answer? I’m not quite sure. I stood in front of a classroom of parents, siblings, and persons struggling with mental health issues, lecturing about depression. I can tell you about the complex interplay of biologic, psychological, and social factors that can lead one to become depressed. I can tell you the prevalence of depression in today’s society, and how it is rising among all age groups. I can tell you a myriad of different treatments, from pharmacologic to therapeutic to procedural, for depression. But how, from a parent’s perspective, can you connect with your child struggling with depression when they do not want your help? That I cannot tell you, at least not yet, anyways.

I had connected with the National Alliance on Mental Illness (NAMI) in the Fall of 2018, when a patient of mine was discharged from hospitalization and told by a faith-based substance use treatment program that he would not be allowed to use any “mind-altering” medications when he returned to their program. Concerned about my patient, whom I had just stabilized with the use of medications, I did my best to work through that organization’s resistance to psychotropic medications. When that failed, I reached out to NAMI for help in advocating for persons with mental illness. My involvement escalated to giving a lecture on “Living with Depression” to our local chapter of approximately 25 individuals that night. I had expected to lecture to an engaged crowd about what I thought was my immense knowledge of depression, from diagnosis to development to treatment. What I had not expected, however, was to have a learning experience of my own.

I stood at the front of the room, listening to story after story of persons with depression and their family members discussing their experiences. Throughout the 90-minute lecture, my emotions ranged from being impressed to shocked, scared, and, ultimately, proud. For the past year and 7 months, I had been spending time with persons with mental illness on what was likely the worst days of their lives. I had seen a variety of severe presentations, from grossly psychotic to acutely manic to majorly depressed to highly agitated. With that wealth of experience, I had thought I was becoming an expert; however, at the front of that classroom that night, I realized how little I actually knew. Yes, I had contemplated before how much severe mental illness and hospitalization could affect a person and their loved ones. However, it was a different level of understanding to hear first-hand accounts of the loss of relationships, the struggle to connect, and the fall-out from intensive inpatient treatment.

In residency, we spend what seems like an immeasurable amount of time on inpatient psychiatric units, in outpatient clinics, and everywhere in between. We see so many patients on a daily, weekly, monthly, and yearly basis that it becomes easy to lose the individuality of each patient. We start associating patients with their disorder, rather than with who they are. However, if we take a step back and allow a larger perspective—one that considers not only the patient but their families and communities—we likely would be able to provide greater and more comprehensive care.

My experience at NAMI was one that I will treasure forever. It opened my eyes to struggles that had I failed to even notice, and for that, and many other connections I made, I am grateful to have been blessed with this experience. My greatest recommendation to my fellow residents would be to engage with your local community organizations in the hope that you, too, can have an eye-opening experience that will strengthen your practice.

Two patients were admitted to our unit at the same time: Mr. P, age 27, an architect with unspecified personality disorder, and Mr. D, age 62, a bank manager who has had bipolar disorder for 40 years and was experiencing a moderate depressive episode. Mr. P’s discomfort with the treatment team informing him of his treatment plan was evident, and he discussed at length his terms and stipulations for management. Mr. D, on the other hand, was loath to shoulder the burden of any decision-making, even in minor matters such as what time he should take his daily walk.

Patient autonomy is a central factor in the present-day doctor–patient equation. In psychiatry, this is sometimes further complicated by a patient’s impaired judgment and lowered decision-making capacity (DMC). In our clinical practice, we often notice that younger patients (ie, millennials) prefer to have autonomy rather than being given instructions, which they may find patronizing, whereas the older generation relies more on the doctor for decision-making.

What the decision-making process entails

The decision-making process involves 3 steps:

• information gathering
• deliberation
• implementation.

Decision-making preferences fall on a spectrum that ranges from paternalism at one end to autonomy on the other, with many intervening components, characterized by varying amounts of responsibility shared between doctor and patient.¹ This typically comes into play when there is more than one treatment option with similar outcomes.² Paternalism is defined as an action performed with the intent of promoting another’s good but occurring against the other’s will, or without consent.³ Here, the patient is not privy to the deliberation process, and no explanations are provided.¹Hard paternalism focuses on doing good for the patient rather than respecting his or her decision-making, whereas soft paternalism implies trying to raise one final red flag, but ultimately not standing in the way of the patient’s choice.⁴

Two other decision-making constructs are shared decision-making (SDM) and informed decision-making (IDM). In SDM, the deliberation process involves participation of both patient and doctor, with active discussion and a final decision after both parties reach an agreement. In IDM, the deliberation is conducted solely by the patient, after he or she receives all information. Shared decision-making and IDM are frequently used interchangeably, but in the latter, the doctor has no role other than to provide information.^1,5

Before choosing SDM or IDM, it is necessary to assess the patient’s DMC—the ability to understand information about choices, make a judgment that respects personal values, understand potential outcomes, and freely communicate his or her wishes.⁶

Benefits and risks

The progression from paternalism to autonomy began in the mid-20th century as a consequence of the Nuremberg Trials, from which the concept of “informed consent” first came into existence.⁷ The Indian value system has always regarded the medical profession and its practitioners with high esteem, as evidenced by the Sanskrit quote “Vaidyo Narayano Harihi,” which translates to “The doctor is God.” A significant chunk of the Indian population still considers the doctor’s word to be law, and they hand over health-related decisions to medical professionals. Here, the expectation of a paternalistic attitude is decidedly unequivocal.

Continue to: Of course...

Of course, there are pros and cons to every approach. Making patients’ independence a priority is the highest virtue of autonomy, but in such cases a patient may have difficulty comprehending medical consequences, and therefore may miss out on the benefits of a sound professional perspective. Paternalism may be superior medically, but the doctor may not be aware of all patient-specific factors, and it would not be prudent to make a decision for a patient without being privy to the entire picture.

The 21st century has witnessed a change in attitudes regarding medical care. With an increasing interest in patient autonomy, it is time for us to adopt these changes and move towards the patient-centred end of the spectrum. However, this should occur only after the patient improves enough symptomatically to regain DMC; autonomy is unlikely to be appropriate for patients with serious mental illness. Ideally, SDM includes the best of both worlds, and results in optimal outcomes. However, when SDM breaks down, a selective, soft paternalistic attitude would be most beneficial, without impinging on the patient’s basic personal rights.

Two patients were admitted to our unit at the same time: Mr. P, age 27, an architect with unspecified personality disorder, and Mr. D, age 62, a bank manager who has had bipolar disorder for 40 years and was experiencing a moderate depressive episode. Mr. P’s discomfort with the treatment team informing him of his treatment plan was evident, and he discussed at length his terms and stipulations for management. Mr. D, on the other hand, was loath to shoulder the burden of any decision-making, even in minor matters such as what time he should take his daily walk.

Patient autonomy is a central factor in the present-day doctor–patient equation. In psychiatry, this is sometimes further complicated by a patient’s impaired judgment and lowered decision-making capacity (DMC). In our clinical practice, we often notice that younger patients (ie, millennials) prefer to have autonomy rather than being given instructions, which they may find patronizing, whereas the older generation relies more on the doctor for decision-making.

What the decision-making process entails

The decision-making process involves 3 steps:

• information gathering
• deliberation
• implementation.

Decision-making preferences fall on a spectrum that ranges from paternalism at one end to autonomy on the other, with many intervening components, characterized by varying amounts of responsibility shared between doctor and patient.¹ This typically comes into play when there is more than one treatment option with similar outcomes.² Paternalism is defined as an action performed with the intent of promoting another’s good but occurring against the other’s will, or without consent.³ Here, the patient is not privy to the deliberation process, and no explanations are provided.¹Hard paternalism focuses on doing good for the patient rather than respecting his or her decision-making, whereas soft paternalism implies trying to raise one final red flag, but ultimately not standing in the way of the patient’s choice.⁴

Two other decision-making constructs are shared decision-making (SDM) and informed decision-making (IDM). In SDM, the deliberation process involves participation of both patient and doctor, with active discussion and a final decision after both parties reach an agreement. In IDM, the deliberation is conducted solely by the patient, after he or she receives all information. Shared decision-making and IDM are frequently used interchangeably, but in the latter, the doctor has no role other than to provide information.^1,5

Before choosing SDM or IDM, it is necessary to assess the patient’s DMC—the ability to understand information about choices, make a judgment that respects personal values, understand potential outcomes, and freely communicate his or her wishes.⁶

Benefits and risks

The progression from paternalism to autonomy began in the mid-20th century as a consequence of the Nuremberg Trials, from which the concept of “informed consent” first came into existence.⁷ The Indian value system has always regarded the medical profession and its practitioners with high esteem, as evidenced by the Sanskrit quote “Vaidyo Narayano Harihi,” which translates to “The doctor is God.” A significant chunk of the Indian population still considers the doctor’s word to be law, and they hand over health-related decisions to medical professionals. Here, the expectation of a paternalistic attitude is decidedly unequivocal.

Continue to: Of course...

Of course, there are pros and cons to every approach. Making patients’ independence a priority is the highest virtue of autonomy, but in such cases a patient may have difficulty comprehending medical consequences, and therefore may miss out on the benefits of a sound professional perspective. Paternalism may be superior medically, but the doctor may not be aware of all patient-specific factors, and it would not be prudent to make a decision for a patient without being privy to the entire picture.

The 21st century has witnessed a change in attitudes regarding medical care. With an increasing interest in patient autonomy, it is time for us to adopt these changes and move towards the patient-centred end of the spectrum. However, this should occur only after the patient improves enough symptomatically to regain DMC; autonomy is unlikely to be appropriate for patients with serious mental illness. Ideally, SDM includes the best of both worlds, and results in optimal outcomes. However, when SDM breaks down, a selective, soft paternalistic attitude would be most beneficial, without impinging on the patient’s basic personal rights.

Two patients were admitted to our unit at the same time: Mr. P, age 27, an architect with unspecified personality disorder, and Mr. D, age 62, a bank manager who has had bipolar disorder for 40 years and was experiencing a moderate depressive episode. Mr. P’s discomfort with the treatment team informing him of his treatment plan was evident, and he discussed at length his terms and stipulations for management. Mr. D, on the other hand, was loath to shoulder the burden of any decision-making, even in minor matters such as what time he should take his daily walk.

Patient autonomy is a central factor in the present-day doctor–patient equation. In psychiatry, this is sometimes further complicated by a patient’s impaired judgment and lowered decision-making capacity (DMC). In our clinical practice, we often notice that younger patients (ie, millennials) prefer to have autonomy rather than being given instructions, which they may find patronizing, whereas the older generation relies more on the doctor for decision-making.

What the decision-making process entails

The decision-making process involves 3 steps:

• information gathering
• deliberation
• implementation.

Decision-making preferences fall on a spectrum that ranges from paternalism at one end to autonomy on the other, with many intervening components, characterized by varying amounts of responsibility shared between doctor and patient.¹ This typically comes into play when there is more than one treatment option with similar outcomes.² Paternalism is defined as an action performed with the intent of promoting another’s good but occurring against the other’s will, or without consent.³ Here, the patient is not privy to the deliberation process, and no explanations are provided.¹Hard paternalism focuses on doing good for the patient rather than respecting his or her decision-making, whereas soft paternalism implies trying to raise one final red flag, but ultimately not standing in the way of the patient’s choice.⁴

Two other decision-making constructs are shared decision-making (SDM) and informed decision-making (IDM). In SDM, the deliberation process involves participation of both patient and doctor, with active discussion and a final decision after both parties reach an agreement. In IDM, the deliberation is conducted solely by the patient, after he or she receives all information. Shared decision-making and IDM are frequently used interchangeably, but in the latter, the doctor has no role other than to provide information.^1,5

Before choosing SDM or IDM, it is necessary to assess the patient’s DMC—the ability to understand information about choices, make a judgment that respects personal values, understand potential outcomes, and freely communicate his or her wishes.⁶

Benefits and risks

The progression from paternalism to autonomy began in the mid-20th century as a consequence of the Nuremberg Trials, from which the concept of “informed consent” first came into existence.⁷ The Indian value system has always regarded the medical profession and its practitioners with high esteem, as evidenced by the Sanskrit quote “Vaidyo Narayano Harihi,” which translates to “The doctor is God.” A significant chunk of the Indian population still considers the doctor’s word to be law, and they hand over health-related decisions to medical professionals. Here, the expectation of a paternalistic attitude is decidedly unequivocal.

Continue to: Of course...

Of course, there are pros and cons to every approach. Making patients’ independence a priority is the highest virtue of autonomy, but in such cases a patient may have difficulty comprehending medical consequences, and therefore may miss out on the benefits of a sound professional perspective. Paternalism may be superior medically, but the doctor may not be aware of all patient-specific factors, and it would not be prudent to make a decision for a patient without being privy to the entire picture.

The 21st century has witnessed a change in attitudes regarding medical care. With an increasing interest in patient autonomy, it is time for us to adopt these changes and move towards the patient-centred end of the spectrum. However, this should occur only after the patient improves enough symptomatically to regain DMC; autonomy is unlikely to be appropriate for patients with serious mental illness. Ideally, SDM includes the best of both worlds, and results in optimal outcomes. However, when SDM breaks down, a selective, soft paternalistic attitude would be most beneficial, without impinging on the patient’s basic personal rights.

I had the unique opportunity to attend a civilian medical school followed by residency and fellowship training along civilian providers, and I often was asked about my military experience. The more time I spent with civilian providers, the more I realized how unaware they are about the intricacies of military lifestyle and culture.

Of course, this makes sense. During the draft era, almost every family had a member who served, and more people were exposed to the uniqueness of military culture.¹ However, with the shift to an all-volunteer military came a decrease in the number of both active duty members and veterans.² Consequently, today’s society is generally less aware of the realities of the military lifestyle. This is especially true among people born after the Vietnam War, whose knowledge about military life is frequently limited to movies and video games. These movies and games are as accurate a reflection of military life as watching TV series such as ER or The Resident are for learning what it’s like to be a physician. To add to the problem, most medical schools and residency training curricula include little information about military culture.³ As a result, psychiatrists, like many other physicians, often feel unequipped to provide care for veterans, current military personnel, and their loved ones.⁴ At the very least, most psychiatrists are unaware of the differences between military and civilian cultures.

Veterans, current military members, and their families who seek mental health services outside the Veterans Affairs (VA) and military treatment facilities are more likely to encounter a clinician who does not feel comfortable with the nuances of the military lifestyle and its challenges.³ Facing a physician with limited familiarity with their experiences, and out of fear of being misunderstood, patients may not feel comfortable disclosing pertinent details.

The US military has its own culture, lingo, customs, rules, and regulations. Its structure is hierarchical and mission-oriented. The moment a person joins the military, he or she falls under a set of legal guidelines of the Uniform Code of Military Justice (UCMJ).⁵ For example, extra-marital sexual conduct, fistfighting (not in combat), disrespecting superior officers, and insubordination are all punishable under UCMJ.^5,6 Active duty military members are also prohibited from suing the federal government for injuries.⁷ The Health Insurance Portability and Accountability Act (HIPAA) permits protected health information of Armed Forces personnel to be disclosed under special circumstances. These include fitness for duty determinations, fitness to perform a particular assignment, or other activities necessary for the military mission.⁸ A mental health provider’s understanding of the unique aspects of military culture can positively influence the patient-provider relationship whether the patient is still serving, has left the military, or is a family member of a current or former military member.

Not all military veterans qualify for VA health care. For example, those who didn’t serve the required time on active duty, those whose injury existed prior to joining the military and was not worsened by their military service, and those discharged under other-than-honorable, bad conduct, or dishonorable conditions are unlikely to qualify.⁹ Other veterans simply prefer to be privately treated outside the VA. However, despite where a veteran receives treatment, the clinician’s knowledge of important military concepts can facilitate rapport-building and providing a safe space for disclosure of pertinent history. Obtaining a military history that includes (for example) years of service, number and location of deployments, combat experience, and number of transfers can help with understanding the biopsychosocial factors contributing to the diagnosis and important treatment needs.

While military dependents (spouses and children) don’t wear uniforms, they are also affected by the service and sacrifices of the military member. Spouses have to deal with adjusting to the military lifestyle, searching for new housing and jobs, finding schools for children, and separation and reconnection with a military member. Military children are not spared, either. They, too, have to leave their friends and find new ones, and adjust to new places, routines, and schools, knowing that in 2 to 3 years they likely will have to move again.

As a military member, mother, and spouse of a former military member, I know how life-changing military service can be for the entire family. I encourage all physicians to start routinely asking if their patient or his or her loved ones have ever been in the military, because a positive answer could help you to better understand the patient and provide the most appropriate, person-centered, culturally-informed treatment.

I had the unique opportunity to attend a civilian medical school followed by residency and fellowship training along civilian providers, and I often was asked about my military experience. The more time I spent with civilian providers, the more I realized how unaware they are about the intricacies of military lifestyle and culture.

Of course, this makes sense. During the draft era, almost every family had a member who served, and more people were exposed to the uniqueness of military culture.¹ However, with the shift to an all-volunteer military came a decrease in the number of both active duty members and veterans.² Consequently, today’s society is generally less aware of the realities of the military lifestyle. This is especially true among people born after the Vietnam War, whose knowledge about military life is frequently limited to movies and video games. These movies and games are as accurate a reflection of military life as watching TV series such as ER or The Resident are for learning what it’s like to be a physician. To add to the problem, most medical schools and residency training curricula include little information about military culture.³ As a result, psychiatrists, like many other physicians, often feel unequipped to provide care for veterans, current military personnel, and their loved ones.⁴ At the very least, most psychiatrists are unaware of the differences between military and civilian cultures.

Veterans, current military members, and their families who seek mental health services outside the Veterans Affairs (VA) and military treatment facilities are more likely to encounter a clinician who does not feel comfortable with the nuances of the military lifestyle and its challenges.³ Facing a physician with limited familiarity with their experiences, and out of fear of being misunderstood, patients may not feel comfortable disclosing pertinent details.

The US military has its own culture, lingo, customs, rules, and regulations. Its structure is hierarchical and mission-oriented. The moment a person joins the military, he or she falls under a set of legal guidelines of the Uniform Code of Military Justice (UCMJ).⁵ For example, extra-marital sexual conduct, fistfighting (not in combat), disrespecting superior officers, and insubordination are all punishable under UCMJ.^5,6 Active duty military members are also prohibited from suing the federal government for injuries.⁷ The Health Insurance Portability and Accountability Act (HIPAA) permits protected health information of Armed Forces personnel to be disclosed under special circumstances. These include fitness for duty determinations, fitness to perform a particular assignment, or other activities necessary for the military mission.⁸ A mental health provider’s understanding of the unique aspects of military culture can positively influence the patient-provider relationship whether the patient is still serving, has left the military, or is a family member of a current or former military member.

Not all military veterans qualify for VA health care. For example, those who didn’t serve the required time on active duty, those whose injury existed prior to joining the military and was not worsened by their military service, and those discharged under other-than-honorable, bad conduct, or dishonorable conditions are unlikely to qualify.⁹ Other veterans simply prefer to be privately treated outside the VA. However, despite where a veteran receives treatment, the clinician’s knowledge of important military concepts can facilitate rapport-building and providing a safe space for disclosure of pertinent history. Obtaining a military history that includes (for example) years of service, number and location of deployments, combat experience, and number of transfers can help with understanding the biopsychosocial factors contributing to the diagnosis and important treatment needs.

While military dependents (spouses and children) don’t wear uniforms, they are also affected by the service and sacrifices of the military member. Spouses have to deal with adjusting to the military lifestyle, searching for new housing and jobs, finding schools for children, and separation and reconnection with a military member. Military children are not spared, either. They, too, have to leave their friends and find new ones, and adjust to new places, routines, and schools, knowing that in 2 to 3 years they likely will have to move again.

As a military member, mother, and spouse of a former military member, I know how life-changing military service can be for the entire family. I encourage all physicians to start routinely asking if their patient or his or her loved ones have ever been in the military, because a positive answer could help you to better understand the patient and provide the most appropriate, person-centered, culturally-informed treatment.

I had the unique opportunity to attend a civilian medical school followed by residency and fellowship training along civilian providers, and I often was asked about my military experience. The more time I spent with civilian providers, the more I realized how unaware they are about the intricacies of military lifestyle and culture.

Of course, this makes sense. During the draft era, almost every family had a member who served, and more people were exposed to the uniqueness of military culture.¹ However, with the shift to an all-volunteer military came a decrease in the number of both active duty members and veterans.² Consequently, today’s society is generally less aware of the realities of the military lifestyle. This is especially true among people born after the Vietnam War, whose knowledge about military life is frequently limited to movies and video games. These movies and games are as accurate a reflection of military life as watching TV series such as ER or The Resident are for learning what it’s like to be a physician. To add to the problem, most medical schools and residency training curricula include little information about military culture.³ As a result, psychiatrists, like many other physicians, often feel unequipped to provide care for veterans, current military personnel, and their loved ones.⁴ At the very least, most psychiatrists are unaware of the differences between military and civilian cultures.

Veterans, current military members, and their families who seek mental health services outside the Veterans Affairs (VA) and military treatment facilities are more likely to encounter a clinician who does not feel comfortable with the nuances of the military lifestyle and its challenges.³ Facing a physician with limited familiarity with their experiences, and out of fear of being misunderstood, patients may not feel comfortable disclosing pertinent details.

The US military has its own culture, lingo, customs, rules, and regulations. Its structure is hierarchical and mission-oriented. The moment a person joins the military, he or she falls under a set of legal guidelines of the Uniform Code of Military Justice (UCMJ).⁵ For example, extra-marital sexual conduct, fistfighting (not in combat), disrespecting superior officers, and insubordination are all punishable under UCMJ.^5,6 Active duty military members are also prohibited from suing the federal government for injuries.⁷ The Health Insurance Portability and Accountability Act (HIPAA) permits protected health information of Armed Forces personnel to be disclosed under special circumstances. These include fitness for duty determinations, fitness to perform a particular assignment, or other activities necessary for the military mission.⁸ A mental health provider’s understanding of the unique aspects of military culture can positively influence the patient-provider relationship whether the patient is still serving, has left the military, or is a family member of a current or former military member.

Not all military veterans qualify for VA health care. For example, those who didn’t serve the required time on active duty, those whose injury existed prior to joining the military and was not worsened by their military service, and those discharged under other-than-honorable, bad conduct, or dishonorable conditions are unlikely to qualify.⁹ Other veterans simply prefer to be privately treated outside the VA. However, despite where a veteran receives treatment, the clinician’s knowledge of important military concepts can facilitate rapport-building and providing a safe space for disclosure of pertinent history. Obtaining a military history that includes (for example) years of service, number and location of deployments, combat experience, and number of transfers can help with understanding the biopsychosocial factors contributing to the diagnosis and important treatment needs.

While military dependents (spouses and children) don’t wear uniforms, they are also affected by the service and sacrifices of the military member. Spouses have to deal with adjusting to the military lifestyle, searching for new housing and jobs, finding schools for children, and separation and reconnection with a military member. Military children are not spared, either. They, too, have to leave their friends and find new ones, and adjust to new places, routines, and schools, knowing that in 2 to 3 years they likely will have to move again.

As a military member, mother, and spouse of a former military member, I know how life-changing military service can be for the entire family. I encourage all physicians to start routinely asking if their patient or his or her loved ones have ever been in the military, because a positive answer could help you to better understand the patient and provide the most appropriate, person-centered, culturally-informed treatment.

Editor’s note: Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.

In this Career Choices, Saeed Ahmed, MD, talked with Cornel Stanciu, MD. Dr. Stanciu is an addiction psychiatrist at Dartmouth’s Geisel School of Medicine, where he is an Assistant Professor, and serves as the Director of Addiction Services at New Hampshire Hospital. He provides support to clinicians managing patients with addictive disorders in a multitude of settings, and also assists with policy making and delivery of addiction care at the state level. He is also the author of Deciphering the Addicted Brain, a guide to help families and the general public better understand addictive disorders.

Dr. Ahmed: What attracted you to pursue subspecialty training in addictive disorders?

Dr. Stanciu: In the early stages of my training, I frequently encountered individuals with medical and mental health disorders whose treatment was impacted by underlying substance use. I soon came to realize any attempts at (for example) managing hypertension in someone with cocaine use disorder, or managing schizophrenia in someone with ongoing cannabis use, were futile. Almost all of my patients receiving treatment for mental health disorders were dependent on tobacco or other substances, and most were interested in cessation. Through mentorship from addiction-trained residency faculty members, I was able to get a taste of the neurobiologic complexities of the disease, something that left me with a desire to develop a deeper understanding of the disease process. Witnessing strikingly positive outcomes with implementation of evidence-based treatment modalities further solidified my path to subspecialty training. Even during that early phase, because I expressed interest in managing these conditions, I was immediately put in a position to share and disseminate any newly acquired knowledge to other specialties as well as the public.

Dr. Ahmed: Could one manage addictive disorders with just general psychiatry training, and what are the differences between the different paths to certification that a resident could undertake?

Dr. Stanciu: Addictive disorders fall under the general umbrella of psychiatric care. Most individuals with these disorders exhibit some degree of mental illness. Medical school curriculum offers on average 2 hours of addiction-related didactics during 4 years. General psychiatry training programs vary significantly in the type of exposure to addiction—some residencies have an affiliated addiction fellowship, others have addiction-trained psychiatrists on staff, but most have none. Ultimately, there is great variability in the degree of comfort in working with individuals with addictive disorders post-residency. Being able to prescribe medications for the treatment of addictive disorders is very different from being familiar with the latest evidence-based recommendations and guidelines; the latter is unlikely to be gleaned simply though residency training. There are 2 routes to specialization after residency: addiction psychiatry, and addiction medicine. The American Board of Psychiatry and Neurology (ABPN) recognized addiction psychiatry as a subspecialty in 1993. Since 1998, completion of a fellowship recognized through the Accreditation Council for Graduate Medical Education has been required for board certification. There are almost 50 programs nationwide with approximately 150 spots. There is no match process for admissions; acceptance is based on a review of application documents and a personal interview. Upon completion of this 1 year of training, candidates sit for the certification exam, which is offered every other year.

Addiction medicine is a fairly new route initially intended to allow non-psychiatric specialties access to addictive disorders training and certification. This is offered through the American Board of Preventive Medicine. There are currently 2 routes to sitting for the exam: through completion of a 1-year addiction medicine fellowship, or through the “practice pathway” still available until 2020. To be eligible for the latter, individuals must provide documentation of clinical experience post-residency, which is quantified as number of hours spent treating patients with addictions, plus any additional courses or training, and must be endorsed by a certified addictionologist.

Continue to: What was your fellowship experience link...

Dr. Ahmed: What was your fellowship experience like, and what should one consider when choosing a program?

Dr. Stanciu: I completed my fellowship training through Dartmouth’s Geisel School of Medicine, and the experience was tremendously valuable. In evaluating programs, one of the starting points is whether you have interest in a formal research track, because several programs include an optional year for that. Most programs tend to provide exposure to the Veterans Affairs system. The 1 year should provide you with broad exposure to all possible settings, all addictive disorders and patient populations, and all treatment modalities, in addition to rigorous didactic sessions. The ideal program should include rotations through methadone treatment centers, intensive outpatient programs, pain and interdisciplinary clinics, detoxification units, and centers for treatment of adolescent and young adults, as well as general medical settings and infectious disease clinics. There should also be close collaboration with psychologists who can provide training in evidence-based therapeutic modalities. During this year, it is vital to expand your knowledge of the ethical and legal regulations of treatment programs, state and federal requirements, insurance complexities, and requirements for privacy and protection of health information. The size of these programs can vary significantly, which may limit the one-on-one time devoted to your training, which is something I personally valued. My faculty was very supportive of academic endeavors, providing guidance, funding, and encouragement for attending and presenting at conferences, publishing papers, and other academic pursuits. Additionally, faculty should be current with emerging literature and willing to develop or implement new protocols and evaluate new pharmacologic therapies.

Dr. Ahmed: What are some of the career options and work settings for addiction psychiatrists?

Dr. Stanciu: Addiction psychiatrists work in numerous settings and various capacities. They can provide subspecialty care directly by seeing patients in outpatient clinics or inpatient addiction treatment centers for detoxification or rehabilitation, or they can work with dual-diagnosis populations in inpatient units. The expansion of telemedicine also holds promise for a role through virtual services. Indirectly, they can serve as a resource for expertise in the field through consultations in medical and psychiatric settings, or through policy making by working with the legislature and public health departments. Additionally, they can help create and integrate new knowledge into practice and educate future generations of physicians and the public.

Dr. Ahmed: What are some of the prevalent disorders and reasons for consultation that you encounter in your daily practice?

Continue to: Dr. Stanciu's response...

Dr. Stanciu: This can vary significantly depending on the setting, geographical region, and demographics of the population. My main non-administrative responsibilities are primarily consultative assisting clinicians at a 200-bed psychiatric hospital to address co-occurring addictive disorders. In short-term units, I am primarily asked to provide input on issues related to various toxidromes and withdrawals and the use of relapse prevention medications for alcohol use disorders as well as the use of buprenorphine or other forms of medication-assisted treatment. I work closely with licensed drug and alcohol counselors in implementing brief interventions as well as facilitating outpatient treatment referrals. Clinicians in longer term units may consult on issues related to pain management in individuals who have addictive disorders, the use of evidence-based pharmacologic agents to address cravings, or the use of relapse prevention medications for someone close to discharge. In terms of specific drugs of abuse, although opioids have recently received a tremendous amount of attention due to the visible costs through overdose deaths, the magnitude of individuals who are losing years of quality life through the use of alcohol and tobacco is significant, and hence this is a large portion of the conditions I encounter. I have also seen an abundance of marijuana use due to decreased perception of harm and increased access.

Dr. Ahmed: What are some of the challenges in working in this field?

Dr. Stanciu: Historically, funding for services has been an issue for clinicians working primarily with addictive disorders from the standpoint of reimbursement, patient access to evidence-based pharmacotherapy, and ability to collaborate with existing levels of care. In recent years, federal funding and policies have changed this, and after numerous studies have found increased cost savings, commercial insurances are providing coverage. A significant challenge also has been public stigma and dealing with a condition that is relapsing-remitting, poorly understood by other specialties and the general public, and sometimes labeled as a defect of character. Several efforts in education have lessened this; however, the impact still takes a toll on patients, who may feel ashamed of their disorder and sometimes are hesitant to take medications because they may believe that they are not “clean” if they depend on a medication for remission. Lastly, recent changes in marijuana policies make conversations about this drug quite difficult because patients often view it as harmless, and the laws governing legality and indications for therapeutic use are slightly ahead of the evidence.

Dr. Ahmed: In what direction do you believe the subspecialty is headed?

Dr. Stanciu: Currently, there are approximately 1,000 certified addiction psychiatrists for the 45 million Americans who have addictive disorders. Smoking and other forms of tobacco use pose significant threats to the 2020 Healthy People Tobacco Use objectives. There is a significant demand for addictionologists in both public and private sectors. As with mental health, demand exceeds supply, and efforts are underway to expand downstream education and increase access to specialists. Several federal laws have been put in place to remove barriers and expand access to care and have paved the way to a brighter future. One is the Affordable Care Act, which requires all insurances including Medicaid to cover the cost of treatment. Second is the Mental Health Parity and Addiction Equity Act, which ensures that the duration and dollar amount of coverage for substance use disorders is comparable to that of medical and surgical care.

Continue to: Another exciting possibility...

Another exciting possibility comes from the world of pharmaceuticals. Some medications have modest efficacy for addressing addictive disorders; however, historically these have been poorly utilized. Enhanced understanding of the neurobiology combined with increased insurance reimbursement should prompt research and new drug development. Some promising agents are already in the pipeline. Research into molecular and gene therapy as a way to better individualize care is also underway.

Going forward, I think we will also encounter a different landscape of drugs. Synthetic agents are emerging and increasing in popularity. Alarmingly, public perception of harm is decreasing. When it comes to cannabis use, I see a rise in pathologic use and the ramifications of this will have a drastic impact, particularly on patients with mental health conditions. We will need to undertake better efforts in monitoring, staying updated, and providing public education campaigns.

Dr. Ahmed: What advice do you have for trainees contemplating subspecialty training in addiction psychiatry?

Dr. Stanciu: I cannot emphasize enough the importance of mentorship. The American Academy of Addiction Psychiatry has a robust system for connecting mentees with mentors at all stages in their careers. This can be extremely helpful, especially in situations where the residency program does not have addiction-trained faculty or rotations through treatment centers. Joining such an organization also grants you access to resources that can help further your enthusiasm. Those interested should also familiarize themselves with currently available pharmacotherapeutic treatments that have evidence supporting efficacy for various addictive disorders, and begin to incorporate these medications into general mental health practice, along with attempts at motivational interviewing. For example, begin discussing naltrexone with patients who have comorbid alcohol use disorders and are interested in reducing their drinking; and varenicline with patients who smoke and are interested in quitting. The outcomes should automatically elicit an interest in pursuing further training in the field!

Editor’s note: Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.

In this Career Choices, Saeed Ahmed, MD, talked with Cornel Stanciu, MD. Dr. Stanciu is an addiction psychiatrist at Dartmouth’s Geisel School of Medicine, where he is an Assistant Professor, and serves as the Director of Addiction Services at New Hampshire Hospital. He provides support to clinicians managing patients with addictive disorders in a multitude of settings, and also assists with policy making and delivery of addiction care at the state level. He is also the author of Deciphering the Addicted Brain, a guide to help families and the general public better understand addictive disorders.

Dr. Ahmed: What attracted you to pursue subspecialty training in addictive disorders?

Dr. Stanciu: In the early stages of my training, I frequently encountered individuals with medical and mental health disorders whose treatment was impacted by underlying substance use. I soon came to realize any attempts at (for example) managing hypertension in someone with cocaine use disorder, or managing schizophrenia in someone with ongoing cannabis use, were futile. Almost all of my patients receiving treatment for mental health disorders were dependent on tobacco or other substances, and most were interested in cessation. Through mentorship from addiction-trained residency faculty members, I was able to get a taste of the neurobiologic complexities of the disease, something that left me with a desire to develop a deeper understanding of the disease process. Witnessing strikingly positive outcomes with implementation of evidence-based treatment modalities further solidified my path to subspecialty training. Even during that early phase, because I expressed interest in managing these conditions, I was immediately put in a position to share and disseminate any newly acquired knowledge to other specialties as well as the public.

Dr. Ahmed: Could one manage addictive disorders with just general psychiatry training, and what are the differences between the different paths to certification that a resident could undertake?

Dr. Stanciu: Addictive disorders fall under the general umbrella of psychiatric care. Most individuals with these disorders exhibit some degree of mental illness. Medical school curriculum offers on average 2 hours of addiction-related didactics during 4 years. General psychiatry training programs vary significantly in the type of exposure to addiction—some residencies have an affiliated addiction fellowship, others have addiction-trained psychiatrists on staff, but most have none. Ultimately, there is great variability in the degree of comfort in working with individuals with addictive disorders post-residency. Being able to prescribe medications for the treatment of addictive disorders is very different from being familiar with the latest evidence-based recommendations and guidelines; the latter is unlikely to be gleaned simply though residency training. There are 2 routes to specialization after residency: addiction psychiatry, and addiction medicine. The American Board of Psychiatry and Neurology (ABPN) recognized addiction psychiatry as a subspecialty in 1993. Since 1998, completion of a fellowship recognized through the Accreditation Council for Graduate Medical Education has been required for board certification. There are almost 50 programs nationwide with approximately 150 spots. There is no match process for admissions; acceptance is based on a review of application documents and a personal interview. Upon completion of this 1 year of training, candidates sit for the certification exam, which is offered every other year.

Addiction medicine is a fairly new route initially intended to allow non-psychiatric specialties access to addictive disorders training and certification. This is offered through the American Board of Preventive Medicine. There are currently 2 routes to sitting for the exam: through completion of a 1-year addiction medicine fellowship, or through the “practice pathway” still available until 2020. To be eligible for the latter, individuals must provide documentation of clinical experience post-residency, which is quantified as number of hours spent treating patients with addictions, plus any additional courses or training, and must be endorsed by a certified addictionologist.

Continue to: What was your fellowship experience link...

Dr. Ahmed: What was your fellowship experience like, and what should one consider when choosing a program?

Dr. Stanciu: I completed my fellowship training through Dartmouth’s Geisel School of Medicine, and the experience was tremendously valuable. In evaluating programs, one of the starting points is whether you have interest in a formal research track, because several programs include an optional year for that. Most programs tend to provide exposure to the Veterans Affairs system. The 1 year should provide you with broad exposure to all possible settings, all addictive disorders and patient populations, and all treatment modalities, in addition to rigorous didactic sessions. The ideal program should include rotations through methadone treatment centers, intensive outpatient programs, pain and interdisciplinary clinics, detoxification units, and centers for treatment of adolescent and young adults, as well as general medical settings and infectious disease clinics. There should also be close collaboration with psychologists who can provide training in evidence-based therapeutic modalities. During this year, it is vital to expand your knowledge of the ethical and legal regulations of treatment programs, state and federal requirements, insurance complexities, and requirements for privacy and protection of health information. The size of these programs can vary significantly, which may limit the one-on-one time devoted to your training, which is something I personally valued. My faculty was very supportive of academic endeavors, providing guidance, funding, and encouragement for attending and presenting at conferences, publishing papers, and other academic pursuits. Additionally, faculty should be current with emerging literature and willing to develop or implement new protocols and evaluate new pharmacologic therapies.

Dr. Ahmed: What are some of the career options and work settings for addiction psychiatrists?

Dr. Stanciu: Addiction psychiatrists work in numerous settings and various capacities. They can provide subspecialty care directly by seeing patients in outpatient clinics or inpatient addiction treatment centers for detoxification or rehabilitation, or they can work with dual-diagnosis populations in inpatient units. The expansion of telemedicine also holds promise for a role through virtual services. Indirectly, they can serve as a resource for expertise in the field through consultations in medical and psychiatric settings, or through policy making by working with the legislature and public health departments. Additionally, they can help create and integrate new knowledge into practice and educate future generations of physicians and the public.

Dr. Ahmed: What are some of the prevalent disorders and reasons for consultation that you encounter in your daily practice?

Continue to: Dr. Stanciu's response...

Dr. Stanciu: This can vary significantly depending on the setting, geographical region, and demographics of the population. My main non-administrative responsibilities are primarily consultative assisting clinicians at a 200-bed psychiatric hospital to address co-occurring addictive disorders. In short-term units, I am primarily asked to provide input on issues related to various toxidromes and withdrawals and the use of relapse prevention medications for alcohol use disorders as well as the use of buprenorphine or other forms of medication-assisted treatment. I work closely with licensed drug and alcohol counselors in implementing brief interventions as well as facilitating outpatient treatment referrals. Clinicians in longer term units may consult on issues related to pain management in individuals who have addictive disorders, the use of evidence-based pharmacologic agents to address cravings, or the use of relapse prevention medications for someone close to discharge. In terms of specific drugs of abuse, although opioids have recently received a tremendous amount of attention due to the visible costs through overdose deaths, the magnitude of individuals who are losing years of quality life through the use of alcohol and tobacco is significant, and hence this is a large portion of the conditions I encounter. I have also seen an abundance of marijuana use due to decreased perception of harm and increased access.

Dr. Ahmed: What are some of the challenges in working in this field?

Dr. Stanciu: Historically, funding for services has been an issue for clinicians working primarily with addictive disorders from the standpoint of reimbursement, patient access to evidence-based pharmacotherapy, and ability to collaborate with existing levels of care. In recent years, federal funding and policies have changed this, and after numerous studies have found increased cost savings, commercial insurances are providing coverage. A significant challenge also has been public stigma and dealing with a condition that is relapsing-remitting, poorly understood by other specialties and the general public, and sometimes labeled as a defect of character. Several efforts in education have lessened this; however, the impact still takes a toll on patients, who may feel ashamed of their disorder and sometimes are hesitant to take medications because they may believe that they are not “clean” if they depend on a medication for remission. Lastly, recent changes in marijuana policies make conversations about this drug quite difficult because patients often view it as harmless, and the laws governing legality and indications for therapeutic use are slightly ahead of the evidence.

Dr. Ahmed: In what direction do you believe the subspecialty is headed?

Dr. Stanciu: Currently, there are approximately 1,000 certified addiction psychiatrists for the 45 million Americans who have addictive disorders. Smoking and other forms of tobacco use pose significant threats to the 2020 Healthy People Tobacco Use objectives. There is a significant demand for addictionologists in both public and private sectors. As with mental health, demand exceeds supply, and efforts are underway to expand downstream education and increase access to specialists. Several federal laws have been put in place to remove barriers and expand access to care and have paved the way to a brighter future. One is the Affordable Care Act, which requires all insurances including Medicaid to cover the cost of treatment. Second is the Mental Health Parity and Addiction Equity Act, which ensures that the duration and dollar amount of coverage for substance use disorders is comparable to that of medical and surgical care.

Continue to: Another exciting possibility...

Another exciting possibility comes from the world of pharmaceuticals. Some medications have modest efficacy for addressing addictive disorders; however, historically these have been poorly utilized. Enhanced understanding of the neurobiology combined with increased insurance reimbursement should prompt research and new drug development. Some promising agents are already in the pipeline. Research into molecular and gene therapy as a way to better individualize care is also underway.

Going forward, I think we will also encounter a different landscape of drugs. Synthetic agents are emerging and increasing in popularity. Alarmingly, public perception of harm is decreasing. When it comes to cannabis use, I see a rise in pathologic use and the ramifications of this will have a drastic impact, particularly on patients with mental health conditions. We will need to undertake better efforts in monitoring, staying updated, and providing public education campaigns.

Dr. Ahmed: What advice do you have for trainees contemplating subspecialty training in addiction psychiatry?

Dr. Stanciu: I cannot emphasize enough the importance of mentorship. The American Academy of Addiction Psychiatry has a robust system for connecting mentees with mentors at all stages in their careers. This can be extremely helpful, especially in situations where the residency program does not have addiction-trained faculty or rotations through treatment centers. Joining such an organization also grants you access to resources that can help further your enthusiasm. Those interested should also familiarize themselves with currently available pharmacotherapeutic treatments that have evidence supporting efficacy for various addictive disorders, and begin to incorporate these medications into general mental health practice, along with attempts at motivational interviewing. For example, begin discussing naltrexone with patients who have comorbid alcohol use disorders and are interested in reducing their drinking; and varenicline with patients who smoke and are interested in quitting. The outcomes should automatically elicit an interest in pursuing further training in the field!

Editor’s note: Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.

In this Career Choices, Saeed Ahmed, MD, talked with Cornel Stanciu, MD. Dr. Stanciu is an addiction psychiatrist at Dartmouth’s Geisel School of Medicine, where he is an Assistant Professor, and serves as the Director of Addiction Services at New Hampshire Hospital. He provides support to clinicians managing patients with addictive disorders in a multitude of settings, and also assists with policy making and delivery of addiction care at the state level. He is also the author of Deciphering the Addicted Brain, a guide to help families and the general public better understand addictive disorders.

Dr. Ahmed: What attracted you to pursue subspecialty training in addictive disorders?

Dr. Stanciu: In the early stages of my training, I frequently encountered individuals with medical and mental health disorders whose treatment was impacted by underlying substance use. I soon came to realize any attempts at (for example) managing hypertension in someone with cocaine use disorder, or managing schizophrenia in someone with ongoing cannabis use, were futile. Almost all of my patients receiving treatment for mental health disorders were dependent on tobacco or other substances, and most were interested in cessation. Through mentorship from addiction-trained residency faculty members, I was able to get a taste of the neurobiologic complexities of the disease, something that left me with a desire to develop a deeper understanding of the disease process. Witnessing strikingly positive outcomes with implementation of evidence-based treatment modalities further solidified my path to subspecialty training. Even during that early phase, because I expressed interest in managing these conditions, I was immediately put in a position to share and disseminate any newly acquired knowledge to other specialties as well as the public.

Dr. Ahmed: Could one manage addictive disorders with just general psychiatry training, and what are the differences between the different paths to certification that a resident could undertake?

Dr. Stanciu: Addictive disorders fall under the general umbrella of psychiatric care. Most individuals with these disorders exhibit some degree of mental illness. Medical school curriculum offers on average 2 hours of addiction-related didactics during 4 years. General psychiatry training programs vary significantly in the type of exposure to addiction—some residencies have an affiliated addiction fellowship, others have addiction-trained psychiatrists on staff, but most have none. Ultimately, there is great variability in the degree of comfort in working with individuals with addictive disorders post-residency. Being able to prescribe medications for the treatment of addictive disorders is very different from being familiar with the latest evidence-based recommendations and guidelines; the latter is unlikely to be gleaned simply though residency training. There are 2 routes to specialization after residency: addiction psychiatry, and addiction medicine. The American Board of Psychiatry and Neurology (ABPN) recognized addiction psychiatry as a subspecialty in 1993. Since 1998, completion of a fellowship recognized through the Accreditation Council for Graduate Medical Education has been required for board certification. There are almost 50 programs nationwide with approximately 150 spots. There is no match process for admissions; acceptance is based on a review of application documents and a personal interview. Upon completion of this 1 year of training, candidates sit for the certification exam, which is offered every other year.

Addiction medicine is a fairly new route initially intended to allow non-psychiatric specialties access to addictive disorders training and certification. This is offered through the American Board of Preventive Medicine. There are currently 2 routes to sitting for the exam: through completion of a 1-year addiction medicine fellowship, or through the “practice pathway” still available until 2020. To be eligible for the latter, individuals must provide documentation of clinical experience post-residency, which is quantified as number of hours spent treating patients with addictions, plus any additional courses or training, and must be endorsed by a certified addictionologist.

Continue to: What was your fellowship experience link...

Dr. Ahmed: What was your fellowship experience like, and what should one consider when choosing a program?

Dr. Stanciu: I completed my fellowship training through Dartmouth’s Geisel School of Medicine, and the experience was tremendously valuable. In evaluating programs, one of the starting points is whether you have interest in a formal research track, because several programs include an optional year for that. Most programs tend to provide exposure to the Veterans Affairs system. The 1 year should provide you with broad exposure to all possible settings, all addictive disorders and patient populations, and all treatment modalities, in addition to rigorous didactic sessions. The ideal program should include rotations through methadone treatment centers, intensive outpatient programs, pain and interdisciplinary clinics, detoxification units, and centers for treatment of adolescent and young adults, as well as general medical settings and infectious disease clinics. There should also be close collaboration with psychologists who can provide training in evidence-based therapeutic modalities. During this year, it is vital to expand your knowledge of the ethical and legal regulations of treatment programs, state and federal requirements, insurance complexities, and requirements for privacy and protection of health information. The size of these programs can vary significantly, which may limit the one-on-one time devoted to your training, which is something I personally valued. My faculty was very supportive of academic endeavors, providing guidance, funding, and encouragement for attending and presenting at conferences, publishing papers, and other academic pursuits. Additionally, faculty should be current with emerging literature and willing to develop or implement new protocols and evaluate new pharmacologic therapies.

Dr. Ahmed: What are some of the career options and work settings for addiction psychiatrists?

Dr. Stanciu: Addiction psychiatrists work in numerous settings and various capacities. They can provide subspecialty care directly by seeing patients in outpatient clinics or inpatient addiction treatment centers for detoxification or rehabilitation, or they can work with dual-diagnosis populations in inpatient units. The expansion of telemedicine also holds promise for a role through virtual services. Indirectly, they can serve as a resource for expertise in the field through consultations in medical and psychiatric settings, or through policy making by working with the legislature and public health departments. Additionally, they can help create and integrate new knowledge into practice and educate future generations of physicians and the public.

Dr. Ahmed: What are some of the prevalent disorders and reasons for consultation that you encounter in your daily practice?

Continue to: Dr. Stanciu's response...

Dr. Stanciu: This can vary significantly depending on the setting, geographical region, and demographics of the population. My main non-administrative responsibilities are primarily consultative assisting clinicians at a 200-bed psychiatric hospital to address co-occurring addictive disorders. In short-term units, I am primarily asked to provide input on issues related to various toxidromes and withdrawals and the use of relapse prevention medications for alcohol use disorders as well as the use of buprenorphine or other forms of medication-assisted treatment. I work closely with licensed drug and alcohol counselors in implementing brief interventions as well as facilitating outpatient treatment referrals. Clinicians in longer term units may consult on issues related to pain management in individuals who have addictive disorders, the use of evidence-based pharmacologic agents to address cravings, or the use of relapse prevention medications for someone close to discharge. In terms of specific drugs of abuse, although opioids have recently received a tremendous amount of attention due to the visible costs through overdose deaths, the magnitude of individuals who are losing years of quality life through the use of alcohol and tobacco is significant, and hence this is a large portion of the conditions I encounter. I have also seen an abundance of marijuana use due to decreased perception of harm and increased access.

Dr. Ahmed: What are some of the challenges in working in this field?

Dr. Stanciu: Historically, funding for services has been an issue for clinicians working primarily with addictive disorders from the standpoint of reimbursement, patient access to evidence-based pharmacotherapy, and ability to collaborate with existing levels of care. In recent years, federal funding and policies have changed this, and after numerous studies have found increased cost savings, commercial insurances are providing coverage. A significant challenge also has been public stigma and dealing with a condition that is relapsing-remitting, poorly understood by other specialties and the general public, and sometimes labeled as a defect of character. Several efforts in education have lessened this; however, the impact still takes a toll on patients, who may feel ashamed of their disorder and sometimes are hesitant to take medications because they may believe that they are not “clean” if they depend on a medication for remission. Lastly, recent changes in marijuana policies make conversations about this drug quite difficult because patients often view it as harmless, and the laws governing legality and indications for therapeutic use are slightly ahead of the evidence.

Dr. Ahmed: In what direction do you believe the subspecialty is headed?

Dr. Stanciu: Currently, there are approximately 1,000 certified addiction psychiatrists for the 45 million Americans who have addictive disorders. Smoking and other forms of tobacco use pose significant threats to the 2020 Healthy People Tobacco Use objectives. There is a significant demand for addictionologists in both public and private sectors. As with mental health, demand exceeds supply, and efforts are underway to expand downstream education and increase access to specialists. Several federal laws have been put in place to remove barriers and expand access to care and have paved the way to a brighter future. One is the Affordable Care Act, which requires all insurances including Medicaid to cover the cost of treatment. Second is the Mental Health Parity and Addiction Equity Act, which ensures that the duration and dollar amount of coverage for substance use disorders is comparable to that of medical and surgical care.

Continue to: Another exciting possibility...

Another exciting possibility comes from the world of pharmaceuticals. Some medications have modest efficacy for addressing addictive disorders; however, historically these have been poorly utilized. Enhanced understanding of the neurobiology combined with increased insurance reimbursement should prompt research and new drug development. Some promising agents are already in the pipeline. Research into molecular and gene therapy as a way to better individualize care is also underway.

Going forward, I think we will also encounter a different landscape of drugs. Synthetic agents are emerging and increasing in popularity. Alarmingly, public perception of harm is decreasing. When it comes to cannabis use, I see a rise in pathologic use and the ramifications of this will have a drastic impact, particularly on patients with mental health conditions. We will need to undertake better efforts in monitoring, staying updated, and providing public education campaigns.

Dr. Ahmed: What advice do you have for trainees contemplating subspecialty training in addiction psychiatry?

Dr. Stanciu: I cannot emphasize enough the importance of mentorship. The American Academy of Addiction Psychiatry has a robust system for connecting mentees with mentors at all stages in their careers. This can be extremely helpful, especially in situations where the residency program does not have addiction-trained faculty or rotations through treatment centers. Joining such an organization also grants you access to resources that can help further your enthusiasm. Those interested should also familiarize themselves with currently available pharmacotherapeutic treatments that have evidence supporting efficacy for various addictive disorders, and begin to incorporate these medications into general mental health practice, along with attempts at motivational interviewing. For example, begin discussing naltrexone with patients who have comorbid alcohol use disorders and are interested in reducing their drinking; and varenicline with patients who smoke and are interested in quitting. The outcomes should automatically elicit an interest in pursuing further training in the field!

Numb and empty, I continued to drive home in a daze. My mind focused only on the light ahead changing from yellow to red. “Remember to step on the brake,” commanded the internal boss to my stunned mind. No tears, I continued to drive as green blinked its eye.

Earlier that afternoon as I stepped out of my second outpatient appointment of the day, the office administrator’s assistant gingerly informed me, “The guy who answered the phone for your no-show said she passed.”

“Passed? Like … died?” I asked in shock.

She nodded. “I looked her up in the system. She passed away 2 Saturdays ago.”

That was only 2 days after the last time I met with her when we celebrated her progress.

“Too soon, too soon in your career,” my attending bemoaned as I shared the news.

Gathering my scattered wit, I smoothed my furrowed brow and forced a smile back into my eyes. I had other patients to see.

Continue to: Soothed by the hum of my car...

Soothed by the hum of my car, my mind replayed our last meeting where hope and active plans had replaced broken hopelessness. For the past 2 weeks, I had erroneously dismissed her no-shows as her volatile borderline personality’s decision to fire me. I was wrong.

Holding things together until a silly domestic dispute unleashed the brewing tornado inside, I stormed upstairs to contain the pain. Behind locked doors, my body shuddered from uncontrollable tears that blinded my eyes. She was the first patient I helped through psychotherapy and the first I lost through suicide.

The news of her death triggered anguish from past suicides of dear friends. Chopper, who blew off his face during our sophomore year of high school. Chopper had already transferred to another school, but those closer to him received a surprise visit with gifts of his personal possessions when he drove up to our school that morning. Later that afternoon, law enforcement found him in a nearby park. In a graduating class of around 100 students, we all grieved.

A few years later, another classmate, Aaron, sank into depression. He, too, shot himself. Just months before I’d received the call requesting my presence at his funeral, he had asked me if I would be his Valentine. Jokingly, I agreed, knowing our paths would never cross after our graduation. At his funeral, his parents insisted that I sat as a member of his immediate family.

Oh … the blinding lies of depression. Those who have fallen prey to suicide never knew the truth: Their lives and their deaths matter.

Even strangers weep.

Numb and empty, I continued to drive home in a daze. My mind focused only on the light ahead changing from yellow to red. “Remember to step on the brake,” commanded the internal boss to my stunned mind. No tears, I continued to drive as green blinked its eye.

Earlier that afternoon as I stepped out of my second outpatient appointment of the day, the office administrator’s assistant gingerly informed me, “The guy who answered the phone for your no-show said she passed.”

“Passed? Like … died?” I asked in shock.

She nodded. “I looked her up in the system. She passed away 2 Saturdays ago.”

That was only 2 days after the last time I met with her when we celebrated her progress.

“Too soon, too soon in your career,” my attending bemoaned as I shared the news.

Gathering my scattered wit, I smoothed my furrowed brow and forced a smile back into my eyes. I had other patients to see.

Continue to: Soothed by the hum of my car...

Soothed by the hum of my car, my mind replayed our last meeting where hope and active plans had replaced broken hopelessness. For the past 2 weeks, I had erroneously dismissed her no-shows as her volatile borderline personality’s decision to fire me. I was wrong.

Holding things together until a silly domestic dispute unleashed the brewing tornado inside, I stormed upstairs to contain the pain. Behind locked doors, my body shuddered from uncontrollable tears that blinded my eyes. She was the first patient I helped through psychotherapy and the first I lost through suicide.

The news of her death triggered anguish from past suicides of dear friends. Chopper, who blew off his face during our sophomore year of high school. Chopper had already transferred to another school, but those closer to him received a surprise visit with gifts of his personal possessions when he drove up to our school that morning. Later that afternoon, law enforcement found him in a nearby park. In a graduating class of around 100 students, we all grieved.

A few years later, another classmate, Aaron, sank into depression. He, too, shot himself. Just months before I’d received the call requesting my presence at his funeral, he had asked me if I would be his Valentine. Jokingly, I agreed, knowing our paths would never cross after our graduation. At his funeral, his parents insisted that I sat as a member of his immediate family.

Oh … the blinding lies of depression. Those who have fallen prey to suicide never knew the truth: Their lives and their deaths matter.

Even strangers weep.

Numb and empty, I continued to drive home in a daze. My mind focused only on the light ahead changing from yellow to red. “Remember to step on the brake,” commanded the internal boss to my stunned mind. No tears, I continued to drive as green blinked its eye.

Earlier that afternoon as I stepped out of my second outpatient appointment of the day, the office administrator’s assistant gingerly informed me, “The guy who answered the phone for your no-show said she passed.”

“Passed? Like … died?” I asked in shock.

She nodded. “I looked her up in the system. She passed away 2 Saturdays ago.”

That was only 2 days after the last time I met with her when we celebrated her progress.

“Too soon, too soon in your career,” my attending bemoaned as I shared the news.

Gathering my scattered wit, I smoothed my furrowed brow and forced a smile back into my eyes. I had other patients to see.

Continue to: Soothed by the hum of my car...

Soothed by the hum of my car, my mind replayed our last meeting where hope and active plans had replaced broken hopelessness. For the past 2 weeks, I had erroneously dismissed her no-shows as her volatile borderline personality’s decision to fire me. I was wrong.

Holding things together until a silly domestic dispute unleashed the brewing tornado inside, I stormed upstairs to contain the pain. Behind locked doors, my body shuddered from uncontrollable tears that blinded my eyes. She was the first patient I helped through psychotherapy and the first I lost through suicide.

The news of her death triggered anguish from past suicides of dear friends. Chopper, who blew off his face during our sophomore year of high school. Chopper had already transferred to another school, but those closer to him received a surprise visit with gifts of his personal possessions when he drove up to our school that morning. Later that afternoon, law enforcement found him in a nearby park. In a graduating class of around 100 students, we all grieved.

A few years later, another classmate, Aaron, sank into depression. He, too, shot himself. Just months before I’d received the call requesting my presence at his funeral, he had asked me if I would be his Valentine. Jokingly, I agreed, knowing our paths would never cross after our graduation. At his funeral, his parents insisted that I sat as a member of his immediate family.

Oh … the blinding lies of depression. Those who have fallen prey to suicide never knew the truth: Their lives and their deaths matter.

Even strangers weep.

Collateral information is a key component obtained during the psychiatric admission process whereby clinicians gather information provided about the patient from the patient’s known contacts. Despite its usefulness in formulating an assessment and plan, collateral information may be misleading and create false biases that lead clinicians to uphold or prolong an involuntary commitment. This raises concern for the need to screen for misleading collateral information, as involuntary admission to an inpatient psychiatric setting can have lasting negative effects on individuals for whom inpatient psychiatric care is not indicated.¹

Here I describe a case in which collateral information obtained about a patient was a primary factor in that patient’s involuntary commitment. However, the patient’s subsequent behavior observed on an inpatient psychiatric unit was entirely inconsistent with those behaviors described by the collateral informant to be “continuous and dangerous.”

CASE

Mr. M, age 18, presented to an emergency psychiatric center for evaluation of dangerous and aggressive behavior. He had a history of autism spectrum disorder (ASD), which was well managed with oral risperidone. He was petitioned for an involuntary psychiatric admission by his foster mother, who reported that Mr. M was aggressive and dangerous, often punching holes in the walls of their home, and that he threatened to assault his foster siblings on several occasions. She detailed a progressively declining history for Mr. M and said that he was “constantly talking to voices in his head that absolutely consume him,” to the extent that Mr. M could not pay attention to his daily tasks. The admitting psychiatrist upheld the petition for involuntary admission, citing that based on the foster’s mother collateral information, Mr. M was deemed to be a danger to others and therefore fulfilled criteria for involuntary psychiatric admission.

Once admitted to the inpatient psychiatric unit, Mr. M was observed to be pleasant, cooperative, and fully engaged in the milieu. At no point during his 7-day admission was he observed to be internally preoccupied or remotely disorganized. Mr. M was switched from oral risperidone to oral haloperidol because he developed acute gynecomastia, and was discharged home.

Does collateral information lead to unfair bias?

The importance of collateral information on the psychiatric admission process must not be understated. It is an opportunity to hear a first-hand account of behaviors consistent with an acute psychiatric disturbance, and guides us in formulating a clinically appropriate assessment and plan. But what happens when our patients’ close contacts or informants provide misleading or unintentionally suboptimal collateral information? How must we reconcile the ethical and legal obligation we have to balance patient autonomy with beneficence?

Studies examining patients’ attitudes toward involuntary admissions have routinely found that patients are less likely than clinical staff to view the involuntary admission as clinically justified.² Consistent with these findings, Mr. M did not view his admission as necessary. At first, he seemed to lack insight regarding the events precipitating his involuntary admission, describing himself not as responding to internal stimuli, but rather, “imaginative because I have autism.” As time went on, though, it was clear that his account of his behavior was in fact correct.

Mr. M’s diagnosis of ASD further complicated the over-reliance on misleading collateral information provided by his foster mother, because the admitting psychiatrist invariably perceived Mr. M as a poor historian. A study examining how subjective histories described by patients with neurologic or psychiatric disorders are perceived by clinicians found physicians had a tendency for negative stereotyping and placed less credence on those patients’ subjective histories.³ Other literature has similarly concluded that there is an urgent need to carefully weigh information supplied to us by collateral informants because the first-hand accounts of perceivably dangerous behavior often are incomplete or misleading.^4-5

Continue to: Ideas for improvement...

Ideas for improvement: respecting patient autonomy

These issues underscore the need for a more thorough review of collateral information to ensure that patient autonomy is not unjustly violated. How do we implement these necessary ideas without creating further undue burden during the admission process? Certainly, I am not suggesting that we evaluate the collateral informant to the degree that we evaluate the patient. However, I have outlined some suggestions for ensuring we act in our patients’ best interest when processing collateral information during an admission:

• Until proven otherwise, the patient’s story is true. If our patient maintains descriptions of his behavior that exist in stark opposition to the collateral information we obtain, we should only not believe the patient if his presentation suggests he may be acutely impaired or a poor historian (such as profound disorganization, overt psychosis, or failing to have capacity).
• Treat symptoms, not diagnoses. In this case, Mr. M was described by his foster mother to be psychotic in addition to having ASD, and an inexperienced psychiatrist may have initiated a titration to a higher antipsychotic dose. However, in the absence of any observable signs of aggression or psychosis, there was simply no indication for further titration of his antipsychotic.
• Document, document, document. When collateral information is supplied to us, it is crucial that we maintain a detailed account of this information. If we have a reason to believe that a patient poses an immediate danger to himself or others, we should carefully document our reasoning so that changes in behavior (if any) can be observed on a day-to-day basis.

Collateral information is a key component obtained during the psychiatric admission process whereby clinicians gather information provided about the patient from the patient’s known contacts. Despite its usefulness in formulating an assessment and plan, collateral information may be misleading and create false biases that lead clinicians to uphold or prolong an involuntary commitment. This raises concern for the need to screen for misleading collateral information, as involuntary admission to an inpatient psychiatric setting can have lasting negative effects on individuals for whom inpatient psychiatric care is not indicated.¹

Here I describe a case in which collateral information obtained about a patient was a primary factor in that patient’s involuntary commitment. However, the patient’s subsequent behavior observed on an inpatient psychiatric unit was entirely inconsistent with those behaviors described by the collateral informant to be “continuous and dangerous.”

CASE

Mr. M, age 18, presented to an emergency psychiatric center for evaluation of dangerous and aggressive behavior. He had a history of autism spectrum disorder (ASD), which was well managed with oral risperidone. He was petitioned for an involuntary psychiatric admission by his foster mother, who reported that Mr. M was aggressive and dangerous, often punching holes in the walls of their home, and that he threatened to assault his foster siblings on several occasions. She detailed a progressively declining history for Mr. M and said that he was “constantly talking to voices in his head that absolutely consume him,” to the extent that Mr. M could not pay attention to his daily tasks. The admitting psychiatrist upheld the petition for involuntary admission, citing that based on the foster’s mother collateral information, Mr. M was deemed to be a danger to others and therefore fulfilled criteria for involuntary psychiatric admission.

Once admitted to the inpatient psychiatric unit, Mr. M was observed to be pleasant, cooperative, and fully engaged in the milieu. At no point during his 7-day admission was he observed to be internally preoccupied or remotely disorganized. Mr. M was switched from oral risperidone to oral haloperidol because he developed acute gynecomastia, and was discharged home.

Does collateral information lead to unfair bias?

The importance of collateral information on the psychiatric admission process must not be understated. It is an opportunity to hear a first-hand account of behaviors consistent with an acute psychiatric disturbance, and guides us in formulating a clinically appropriate assessment and plan. But what happens when our patients’ close contacts or informants provide misleading or unintentionally suboptimal collateral information? How must we reconcile the ethical and legal obligation we have to balance patient autonomy with beneficence?

Studies examining patients’ attitudes toward involuntary admissions have routinely found that patients are less likely than clinical staff to view the involuntary admission as clinically justified.² Consistent with these findings, Mr. M did not view his admission as necessary. At first, he seemed to lack insight regarding the events precipitating his involuntary admission, describing himself not as responding to internal stimuli, but rather, “imaginative because I have autism.” As time went on, though, it was clear that his account of his behavior was in fact correct.

Mr. M’s diagnosis of ASD further complicated the over-reliance on misleading collateral information provided by his foster mother, because the admitting psychiatrist invariably perceived Mr. M as a poor historian. A study examining how subjective histories described by patients with neurologic or psychiatric disorders are perceived by clinicians found physicians had a tendency for negative stereotyping and placed less credence on those patients’ subjective histories.³ Other literature has similarly concluded that there is an urgent need to carefully weigh information supplied to us by collateral informants because the first-hand accounts of perceivably dangerous behavior often are incomplete or misleading.^4-5

Continue to: Ideas for improvement...

Ideas for improvement: respecting patient autonomy

These issues underscore the need for a more thorough review of collateral information to ensure that patient autonomy is not unjustly violated. How do we implement these necessary ideas without creating further undue burden during the admission process? Certainly, I am not suggesting that we evaluate the collateral informant to the degree that we evaluate the patient. However, I have outlined some suggestions for ensuring we act in our patients’ best interest when processing collateral information during an admission:

• Until proven otherwise, the patient’s story is true. If our patient maintains descriptions of his behavior that exist in stark opposition to the collateral information we obtain, we should only not believe the patient if his presentation suggests he may be acutely impaired or a poor historian (such as profound disorganization, overt psychosis, or failing to have capacity).
• Treat symptoms, not diagnoses. In this case, Mr. M was described by his foster mother to be psychotic in addition to having ASD, and an inexperienced psychiatrist may have initiated a titration to a higher antipsychotic dose. However, in the absence of any observable signs of aggression or psychosis, there was simply no indication for further titration of his antipsychotic.
• Document, document, document. When collateral information is supplied to us, it is crucial that we maintain a detailed account of this information. If we have a reason to believe that a patient poses an immediate danger to himself or others, we should carefully document our reasoning so that changes in behavior (if any) can be observed on a day-to-day basis.

Collateral information is a key component obtained during the psychiatric admission process whereby clinicians gather information provided about the patient from the patient’s known contacts. Despite its usefulness in formulating an assessment and plan, collateral information may be misleading and create false biases that lead clinicians to uphold or prolong an involuntary commitment. This raises concern for the need to screen for misleading collateral information, as involuntary admission to an inpatient psychiatric setting can have lasting negative effects on individuals for whom inpatient psychiatric care is not indicated.¹

Here I describe a case in which collateral information obtained about a patient was a primary factor in that patient’s involuntary commitment. However, the patient’s subsequent behavior observed on an inpatient psychiatric unit was entirely inconsistent with those behaviors described by the collateral informant to be “continuous and dangerous.”

CASE

Mr. M, age 18, presented to an emergency psychiatric center for evaluation of dangerous and aggressive behavior. He had a history of autism spectrum disorder (ASD), which was well managed with oral risperidone. He was petitioned for an involuntary psychiatric admission by his foster mother, who reported that Mr. M was aggressive and dangerous, often punching holes in the walls of their home, and that he threatened to assault his foster siblings on several occasions. She detailed a progressively declining history for Mr. M and said that he was “constantly talking to voices in his head that absolutely consume him,” to the extent that Mr. M could not pay attention to his daily tasks. The admitting psychiatrist upheld the petition for involuntary admission, citing that based on the foster’s mother collateral information, Mr. M was deemed to be a danger to others and therefore fulfilled criteria for involuntary psychiatric admission.

Once admitted to the inpatient psychiatric unit, Mr. M was observed to be pleasant, cooperative, and fully engaged in the milieu. At no point during his 7-day admission was he observed to be internally preoccupied or remotely disorganized. Mr. M was switched from oral risperidone to oral haloperidol because he developed acute gynecomastia, and was discharged home.

Does collateral information lead to unfair bias?

The importance of collateral information on the psychiatric admission process must not be understated. It is an opportunity to hear a first-hand account of behaviors consistent with an acute psychiatric disturbance, and guides us in formulating a clinically appropriate assessment and plan. But what happens when our patients’ close contacts or informants provide misleading or unintentionally suboptimal collateral information? How must we reconcile the ethical and legal obligation we have to balance patient autonomy with beneficence?

Studies examining patients’ attitudes toward involuntary admissions have routinely found that patients are less likely than clinical staff to view the involuntary admission as clinically justified.² Consistent with these findings, Mr. M did not view his admission as necessary. At first, he seemed to lack insight regarding the events precipitating his involuntary admission, describing himself not as responding to internal stimuli, but rather, “imaginative because I have autism.” As time went on, though, it was clear that his account of his behavior was in fact correct.

Mr. M’s diagnosis of ASD further complicated the over-reliance on misleading collateral information provided by his foster mother, because the admitting psychiatrist invariably perceived Mr. M as a poor historian. A study examining how subjective histories described by patients with neurologic or psychiatric disorders are perceived by clinicians found physicians had a tendency for negative stereotyping and placed less credence on those patients’ subjective histories.³ Other literature has similarly concluded that there is an urgent need to carefully weigh information supplied to us by collateral informants because the first-hand accounts of perceivably dangerous behavior often are incomplete or misleading.^4-5

Continue to: Ideas for improvement...

Ideas for improvement: respecting patient autonomy

These issues underscore the need for a more thorough review of collateral information to ensure that patient autonomy is not unjustly violated. How do we implement these necessary ideas without creating further undue burden during the admission process? Certainly, I am not suggesting that we evaluate the collateral informant to the degree that we evaluate the patient. However, I have outlined some suggestions for ensuring we act in our patients’ best interest when processing collateral information during an admission:

• Until proven otherwise, the patient’s story is true. If our patient maintains descriptions of his behavior that exist in stark opposition to the collateral information we obtain, we should only not believe the patient if his presentation suggests he may be acutely impaired or a poor historian (such as profound disorganization, overt psychosis, or failing to have capacity).
• Treat symptoms, not diagnoses. In this case, Mr. M was described by his foster mother to be psychotic in addition to having ASD, and an inexperienced psychiatrist may have initiated a titration to a higher antipsychotic dose. However, in the absence of any observable signs of aggression or psychosis, there was simply no indication for further titration of his antipsychotic.
• Document, document, document. When collateral information is supplied to us, it is crucial that we maintain a detailed account of this information. If we have a reason to believe that a patient poses an immediate danger to himself or others, we should carefully document our reasoning so that changes in behavior (if any) can be observed on a day-to-day basis.