Suggested guidelines for e-mail communication in psychiatric practice

BACKGROUND: Physicians and patients are increasingly communicating with one another by e-mail concerning administrative issues, medications, and other aspects of care. The objective of this article is to review existing guidelines for general physicians communicating with patients by e-mail as the basis for developing more specific guidelines for psychiatric practice. METHOD: We review e-mail guidelines previously developed by the American Medical Informatics Association, subsequently promulgated by the American Medical Association, and consider each suggestion for clinical and administrative practice from the perspective of psychiatric practice. Case vignettes illustrate several of these issues. RESULTS: We suggest expansion and/or modification of existing guidelines to address more directly issues of specific concern in psychiatric practice. CONCLUSION: Existing general guidelines concerning the use of e-mail in medical practice are useful starting points for psychiatric practice. Psychiatrists must pay particular attention to issues of confidentiality, communicative tone, and professional boundaries. With cautious application, e-mail may provide a useful tool for enhancing communication and treatment options for psychiatrists and their patients.     

Guidelines for ethical behavior relating to clinical practice issues in electrodiagnostic medicine

Ln 1993, the American Association of Electrodiagnostic Medicine formed an Ethics and Peer Review Committee in concert with a renewed initiative by organized medicine to emphasize ethical standards. Guidelines for ethical behavior relating to clinical practice issues in electrodiagnostic medicine were developed to formalize the standards of professional behavior for electrodiagnostic medical consultants and were approved by the AAEM Board of Directors in April 1994. The guidelines are modeled after the Code of Professional Conduct of the American Academy of Neurology and are consistent with the Guidelines in Electrodiagnostic Medicine of the American Association of Electrodiagnostic Medicine and Principles of Medical Ethics as adopted by the American Medical Association. The Guidelines may provide grounds for discipliary action under Article X of the AAEM Bylaws.     

The role of pharmacologic treatment guidelines for bipolar disorder

With the growth in the number of pharmacologic options available for the treatment of bipolar disorder, clinicians face a challenge in appropriately selecting and sequencing newer and older treatments. Because evidence-based practice has been suggested as a way to improve outcomes across specialties in medicine, a number of practice guidelines and treatment algorithms for bipolar disorder have been developed to aid clinical decision-making. Most of these guidelines and algorithms are based on detailed reviews of the medical literature, with an emphasis on systematic reviews and randomized, controlled trials. Some guidelines incorporate a consensus of expert opinion when the literature does not provide clear evidence. This review examines areas of overlap and discordance in practice guidelines issued by the American Psychiatric Association and the British Association for Psychopharmacology, as well as treatment algorithms developed by the Expert Consensus Guideline Series and the Texas Medical Algorithm Project.     

Practice Protocols, Parameters, Pathways, and Guidelines: A Review

The evolution of clinical practice protocols is described within the context of its origins in utilization review and utilization management. Physician concerns and barriers to implementation, as well as the role of the Agency for Health Care Policy and Research (AHCPR) are discussed. An example of competing guidelines from the AHCPR and the American Psychiatric Association is described in detail. The available literature on cost savings related to utilization management and clinical guidelines is reviewed and summarized. With over 1,800 medical practice guidelines catalogued, practice protocols have become ubiquitous and continued research into their cost and impact on quality are needed.     

Guidelines for the treatment of patients with borderline personality disorder

The prevalence of patients with borderline personality disorder in outpatient psychiatric clinics, the severity of their presenting symptoms including potential mortality and the difficulty to treat these poorly collaborative healthseekers are sufficient arguments to justify the need for a practice guideline about their treatment. Supported by a strong experience in the creation of many practice guidelines, the American Psychiatric Association has produced a guide that answers quite well to the scientific criteria of a treatment guide and respects most of the specified requirements emitted by the Canadian Medical Association and the Advisory Committee to Public Health Services of the American Institute of Medicine. A review of the suggested recommendations on psychotherapeutic and pharmacological treatments and their scientific evidence is given followed by comments and a critical discussion.     

The ACCF/AHA Scientific Statement on Syncope

The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have recently published, in both the Journal of the American College of Cardiology (JACC) and Circulation, a Scientific Statement on the Evaluation of Syncope (‘Statement’). This Scientific Statement was commissioned to provide guidance for clinicians regarding the evaluation of patients who present with ‘syncope’. The Statement was not intended to be a formal set of practice guidelines. However, in the absence of generally accepted practice guidelines in North America, the Statement’s potential impact on clinical care may be more far-reaching than expected; it may erroneously be considered to be the authoritative ‘de-facto’ guideline document. This commentary, submitted by a multidisciplinary consortium of more than 60 physicians with expertise in the management of transient loss of consciousness (TLOC), points out that in many respects the ACCF/AHA Syncope Statement fails to address long-standing clinical errors associated with the evaluation of episodes of apparent TLOC, including syncope. If not appropriately revised, the current Statement may lead to both inadequate patient care as well as a potentially damaging legal environment for physicians undertaking evaluation of patients who present with transient loss of consciousness.     

The ACCF/AHA scientific statement on syncope: a document in need of thoughtful revision.

The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have recently published, in both the Journal of the American College of Cardiology (JACC) and Circulation, a Scientific Statement on the Evaluation of Syncope ('Statement'). This Scientific Statement was commissioned to provide guidance for clinicians regarding the evaluation of patients who present with 'syncope'. The Statement was not intended to be a formal set of practice guidelines. However, in the absence of generally accepted practice guidelines in North America, the Statement's potential impact on clinical care may be more far-reaching than expected; it may erroneously be considered to be the authoritative 'de-facto' guideline document. This commentary, submitted by a multidisciplinary consortium of more than 60 physicians with expertise in the management of transient loss of consciousness (TLOC), points out that in many respects the ACCF/AHA Syncope Statement fails to address long-standing clinical errors associated with the evaluation of episodes of apparent TLOC, including syncope. If not appropriately revised, the current Statement may lead to both inadequate patient care as well as a potentially damaging legal environment for physicians undertaking evaluation of patients who present with transient loss of consciousness.     

Official position of the military TBI task force on the role of neuropsychology and rehabilitation psychology in the evaluation, management, and research of military veterans with traumatic brain injury

This Position Statement is a summary of the literature and learning regarding current issues raised by the occurrence, treatment, and study of traumatic brain injury in military service members and veterans. The Report has been approved by the American Academy of Clinical Neuropsychology (AACN), Divisions 40 (Neuropsychology) and 22 (Rehabilitation Psychology) of the American Psychological Association (APA), and the National Academy of Neuropsychology (NAN), with the goal of providing information of relevance on an important public policy matter within their respective areas of expertise. The Report is not intended to establish guidelines or standards for the professional practice of psychology, nor has it been adopted as official policy by the American Psychological Association or any other division or subunit of APA.     

Psychosocial skills training for schizophrenia: lessons from the laboratory

A large body of research supports the efficacy of psychosocial treatments for schizophrenia, particularly learning-based therapies. The Schizophrenia Patient Outcomes Research Team recommended that cognitive-behavioral therapies be used in schizophrenia, and skills training was included in the practice guideline for treating patients with schizophrenia published by the American Psychiatric Association. This article provides an updated review of empirical studies of psychosocial skills training, showing its value in treating patients with schizophrenia as well as its broader clinical effectiveness. Data supporting the efficacy of psychosocial skills training continue to accumulate. Such programs should continue to be included in best practices guidelines and treatment recommendations for schizophrenia. Future clinical service research could be directed toward integration of skills training with other psychosocial treatment methods.     

Why empirically supported psychological treatments are important

The emergence of managed care and similar reimbursement systems that require greater accountability and the development of clinical practice guidelines have increased the importance of evidence-based clinical practice. As a result of these two trends, it appears as though the future of psychotherapy will require clinicians to deliver a psychological intervention that is supported by research. Such treatments exist for a variety of the most common presenting problems (e.g., anxiety disorders, depression) but to date have frequently gone unrecognized and underutilized. The current article will discuss the importance of identifying, promoting, and disseminating empirically supported therapies with an emphasis on the efforts of the American Psychological Association Society of Clinical Psychology's Committee on Science and Practice.     

Metabolic adverse events in patients with mental illness treated with antipsychotics: a primary care perspective

Background: Individuals with mental illness are at a higher risk of medical mortality than the general population, primarily due to an increased risk of cardiovascular disease. There are a number of modifiable metabolic risk factors associated with some atypical antipsychotics that warrant careful monitoring and treatment in both psychiatric and primary care practice if the risk of cardiovascular disease is to be effectively reduced.Data Sources: Previous guidelines have focused on awareness of metabolic risk factors in psychiatry, yet few articles have appeared in the primary care-focused journals. We present pragmatic guidelines that focus on monitoring metabolic abnormalities in primary care based on established guidelines, including joint recommendations of the American Diabetes Association, the American Psychiatric Association, the American Association of Clinical Endocrinologists, and the North American Association for the Study of Obesity, and the Mount Sinai conference.Data Synthesis: All patients receiving atypical antipsychotic agents associated with metabolic adverse events should be routinely monitored for weight gain and abnormalities in blood glucose and lipid levels. Effective communication and collaboration between mental health and primary care services and better access to primary care screening and treatment for individuals with mental health problems are needed.Conclusion: There is a clear need for awareness among primary care physicians, particularly as metabolic effects of atypical antipsychotics such as blood pressure and glucose and lipid levels are possibly best monitored in a primary care setting.     

Indicators of carotid endarterectomy: AHA guidelines

Carotid endarterectomy (CEA) is surgical therapy used in treating patients with a stenosis of the extracranial internal carotid artery (ICA). Guidelines for CEA have been published by the American Heart Association. We discuss these guidelines and the important clinical trials used to generate the guidelines. For patients with symptoms referable to an ipsilateral stenosis, CEA has been proven to be more beneficial than standard medical therapy in preventing subsequent strokes, especially in patients with a severe ICA stenosis. The benefits of CEA in asymptomatic patients are more controversial, and the guidelines are less clear. We conclude with a discussion of our typical use of CEA in several clinical scenarios.     

Guidelines for ethical behavior relating to clinical practice issues in neuromuscular and electrodiagnostic medicine

The American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) developed guidelines to formalize the ethical standards that neuromuscular and electrodiagnostic (EDx) physicians should observe in their clinical and scientific activities. Neuromuscular and EDx medicine is a subspecialty of medicine that focuses on evaluation, diagnosis, and comprehensive medical management, including rehabilitation of individuals with neuromuscular disorders. Physicians working in this subspecialty focus on disorders of the motor unit, including muscle, neuromuscular junction, axon, plexus, nerve root, anterior horn cell, and the peripheral nerves (motor and sensory). The neuromuscular and EDx physician's goal is to diagnose and treat these conditions to mitigate their impact and improve the patient's quality of life. The guidelines are consistent with the Principles of Medical Ethics adopted by the American Medical Association and represent a revision of previous AANEM guidelines. Muscle Nerve 52 : 1122–1129, 2015     

Perspectives on the Clinical Use of Pharmacogenetic Testing in Late-Life Mental Healthcare: A Survey of the American Association of Geriatric Psychiatry Membership

ObjectiveTo assess perspectives on pharmacogenetic (PGx) testing among members of the American Association of Geriatric Psychiatry (AAGP).DesignCross-sectional survey.ParticipantsMembers of the AAGP.MeasurementsAnonymous web-based survey consisting of 41 items covering experiences, indications, barriers, facilitators and ethical, legal and social implications for PGx testing.ResultsA total of 124 surveys were completed (response rate = 13%). Most respondents (60%) had used PGx testing but an equal proportion (58%) was uncertain about the clinical usefulness of PGx testing in late-life mental health. Despite self-reported confidence in the ability to order and interpret PGx testing, 60% of respondents felt there was not enough clinical evidence for them to use PGx testing in their practice. This was compounded by uncertainties related to their ethical obligation and legal liability when interpreting and using (or not using) PGx testing results. Respondents strongly affirmed that clinical and legal guidelines for PGx testing in older adults are needed and would be helpful.ConclusionThe findings suggest additional PGx research and physician education in late-life mental healthcare settings is required to reconcile uncertainties related to the clinical efficacy and ethico-legal aspects of PGx testing as well as address current knowledge barriers to testing uptake. These efforts would be further facilitated by the development of clinical practice guidelines to ensure equitable access to testing and standardized implementation of PGx-informed prescribing in older adults.     

Using algorithms and computerized decision support systems to treat major depression

The American Psychiatric Association practice guidelines for treating major depressive disorder advocate using measurement-based care and treatment algorithms, which have been shown to be effective strategies in improving patient outcomes. However, in practice, clinicians may avoid using algorithms and guidelines due to barriers such as lack of time, lack of staff support, and the perceived inflexibility of algorithms. Computerized decision support systems (CDSS) are one approach to increasing guideline adherence. A CDSS can make measurement-based care strategies accessible and user-friendly for physicians and staff, individualize treatment options according to each patient's circumstances, and provide guideline information at the point of care. In addition, a CDSS can be merged with electronic health record systems, which should simplify implementation and increase guideline adherence.     

Guidelines for the Management of Depression During Pregnancy

Guidelines regarding the treatment of depression during pregnancy were recently published by the American Psychiatric Association and the American College of Obstetricians and Gynecologists. We provide a commentary on these guidelines.     

Antithrombotics for secondary prevention of noncardioembolic ischaemic stroke

Antiplatelet therapy is more effective than anticoagulation for the prevention of noncardioembolic ischaemic stroke. The choice of antiplatelet regimen, however, remains contentious. Recent controversies regarding aspirin resistance and the optimal dosing of aspirin, as well as recognition of the variable bioactivation of clopidogrel, have added further confusion to the debate. The American Heart Association (AHA) and American Stroke Association (ASA) recently released their third joint guideline in the past 5 years on secondary stroke prevention. The European Stroke Organisation has published three guidelines on this issue since 2000. These frequent updates have been necessary because of rapidly accumulating data from clinical trials. Careful consideration of the sometimes confusing trial results reveals that the 2011 AHA-ASA guidelines are correct in no longer specifying a 'preferred' antiplatelet regimen from among the choices recently studied. This recommendation does not, however, mean that all antiplatelet regimens should be considered equal. This Review discusses the various antiplatelet regimens, and the trials that led to the rapid evolution of the guidelines for secondary prevention of ischaemic stroke.     

Practice parameters: strategies for survival into the nineties.

In an atmosphere of escalating medical costs, clinical practice guidelines have been proposed as a viable means of achieving cost containment. The approaches to developing standards of practice have historically been varied, and new methods of development have been proposed to incorporate current scientific knowledge and patient preferences for achieving optimal health outcomes. We review the historical, governmental, and health organization approaches to achieve scientifically sound and clinically relevant parameters. The mechanism and the mission of the American Academy of Neurology Quality Standards Subcommittee is reviewed. The Subcommittee has selected the term "practice parameter" in lieu of "practice policy" to be consistent with AMA terminology. Practice parameters may include one or more of the following types of recommendations: standards, guidelines, and options. These three terms reflect varying levels of clinical certainty as determined by the level of objective evidence.     

《2018年版美国意识障碍实践指南》解读

意识障碍(DOC)是指各类脑损伤后出现的持续意识丧失的状态,包括植物状态(VS)和微意识状态(MCS)两个层次。2018年美国神经病学学会(AAN)、美国康复医学会(ACRM)等组织联合发布了针对意识障碍诊断和治疗的指南,指南包括诊断、预后、成人治疗及儿童患者处理4部分,推荐分为三个等级共18条建议,33个临床规范与标准推荐。