Genetic counseling in psychiatry

While psychiatrists may commonly discuss family history in clinical practice, there has been little systematic research documenting the role and effectiveness of genetic counseling for psychiatric disorders. In the coming years, the expected identification of susceptibility genes for psychiatric disorders may bring new opportunities and expectations from patients and families for the clinical translation of research findings in psychiatric genetics. We review evidence for possible increasing demand for genetic counseling, particularly if specific genes related to psychiatric disorders are identified. We then explore both the potential role of genetic counseling for psychiatric disorders and the issues involved in conveying genetic information in the clinical setting. Further research regarding the effectiveness of counseling interventions, as well as additional efforts directed at genetics education for clinicians, will be needed if emerging advances in genetic research are to be incorporated into clinical practice.     

Survey of essential tremor patients on their knowledge about the genetics of the disease.

A group of essential tremor (ET) patients were surveyed on their knowledge of the genetics of ET in order to provide important information to clinicians who care for and educate patients about this disease. ET patients were ascertained from neurologists at Columbia-Presbyterian Medical Center. A 5- to 10-minute survey was administered to assess knowledge of the genetics of ET. Fifty ET patients had been living with their disease for a mean of 24.2 years. Approximately half (n = 27) reported a family history of ET. When asked, "What causes ET," 12 (24%) replied that it was "hereditary." Even among the 27 who reported a family history, only 25.9% replied that it was "hereditary." A minority of patients (12 [24%]) thought that it was "very likely" that other members of their family would develop the disease some day. Three patients were aware that genetic linkage had been established. Our findings suggest that the majority of patients with ET are not well informed about the genetic basis for the disease. Because of recent advances in genetic research, physicians may need to incorporate more genetic information and education into their practice, including information on risk to other family members and genetic testing. It is hoped that these survey results could be used to improve patient education and to provide clinicians with further insight into patients' perspectives.     

Electroconvulsive Therapy-Related Psychiatric Knowledge Among British Anesthetists

Opinion of electroconvulsive therapy (ECT) and ECT-related psychiatric knowledge among anesthetists working in the North Western Health Region of England were investigated; 261 anesthetists returned usable questionnaires. The majority were in favor of ECT for patients as recommended by psychiatrists, and possessed a reasonable knowledge base about related psychiatric issues. A minority were opposed to the use of ECT, lacked rudimentary psychiatric knowledge and held negative misconceptions. Although this does not compromise anesthetic ability, it may have adverse consequences. In particular anesthetists may not appreciate the importance of their role in ECT and may be reluctant to become involved in ECT clinics and research. Attitude and knowledge did not differ significantly when respondents with extensive and recent ECT experience were compared with the remainder. Two thirds of respondents favored anesthetic training including more information about psychiatric aspects of ECT. We recommend improved liasion between anesthetists and psychiatrists during training and in clinical practice.     

Knowledge and attitudes about personalized mental health genomics: narratives from individuals coping with serious mental illness

The present qualitative study examined the personal accounts, elicited via semi-structured interview, of nine United States military veterans with serious mental illness to describe their knowledge, attitudes, and beliefs about psychiatric genetics, genetic testing and counseling for mental illness. The aim of the research was to elucidate issues from the perspective of adults with mental illness that may inform the education and training of mental health providers on basic genetic counseling. Findings suggest that participants had some basic knowledge about genetics, were interested in psychiatric genetic testing, and had an awareness of both positive and negative aspects of genetic test results. Participants tended to have overly optimistic ideas about current advances in psychiatric genetics and were motivated to undergo genetic testing for the good of their families and to benefit society. Implications of findings for research and practice are discussed.     

Genetic counselling for schizophrenia in the era of molecular genetics.

OBJECTIVE: To review the role of genetic counselling for individuals with psychiatric illnesses. METHOD: Using schizophrenia as an example and including updated information about a genetic subtype (22q deletion syndrome), we discuss the value of the genetic counselling process in psychiatry, with support from the literature and our clinical experience. RESULTS: Genetic counselling, the process through which knowledge about the genetics of illnesses is shared, provides information on the inheritance of illnesses and their recurrence risks; addresses the concerns of patients, their families, and their health care providers; and supports patients and their families dealing with these illnesses. For comprehensive medical management, this service should be available to all individuals with schizophrenia and their families. CONCLUSIONS: New findings in the genetics of psychiatric illness may have important clinical implications for patients and their families.     

Variation in Routine Psychiatric Workload: The Role of Financing Source,Managed Care Participation,and Mental Health Workforce Competition

This study was conducted to examine the association between psychiatrists' demographic characteristics, payment source, and managed care participation and psychiatrists' practice workload, and between the supply of other mental health providers in a psychiatrist's county of practice and psychiatrists' practice workload. Data from the 1996 American Psychiatric Association National Survey of Psychiatric Practice were merged with national countywide measures of mental health workforce and environmental data from the 1996 Area Resource File. In comparison to male psychiatrists, female psychiatrists treat fewer patients per week, provide less total hours of weekly patient care, and obtain fewer new monthly referrals. An increase in psychiatrists' managed care participation was associated with only minor increases in the number of patients per week, weekly time spent in clinical care, and number of new monthly referrals. The supply of other mental health providers was not associated with variation in practice workload. Once psychiatrists participate in managed care plans, an increase in their participation rate does not significantly expand clinical practice workload. The supply of other mental health providers was not significantly associated with variation in psychiatrists' workload, which suggests that substitution effects may not be evident with this aspect of psychiatric practice.     

Personal Symbolism in Language Patterns†

With increasing emphasis on understanding genetic contribution to disease, inclusion of all racial and ethnic groups in molecular genetic research is necessary to ensure parity in distribution of research benefits. Blacks are underrepresented in large-scale genetic studies of psychiatric disorders. In an effort to understand the reasons for the underrepresentation, this study explored black participants' attitudes towards genetic research of psychiatric disorders. Twenty-six adults, the majority of whom were black (n = 18) were recruited from a New York City community to participate in six 90-minute focus groups. This paper reports findings about respondents' understanding of genetics and genetic research, and opinions about psychiatric genetic research. Primary themes revealed participants' perceived lack of knowledge about genetics, concerns about potentially harmful study procedures, and confidentiality surrounding mental illness in families. Participation incentives included provision of treatment or related service, monetary compensation, and reporting of results to participants. These findings suggest that recruitment of subjects into genetic studies should directly address procedures, privacy, benefits and follow-up with results. Further, there is critical need to engage communities with education about genetics and mental illness, and provide opportunities for continued discussion about concerns related to genetic research.     

Psychiatrists' knowledge about maternal filicidal thoughts

OBJECTIVE: Child murder by mentally ill mothers is an important public health and psychiatric concern. However, the authors' clinical and forensic experience has been that psychiatrists often do not inquire about maternal thoughts of harming their children. This study sought to elucidate the perceptions of psychiatrists and psychiatric residents regarding the frequency of such thoughts, and to clarify whether they inquire specifically about maternal filicidal thoughts. Psychiatrists were expected to underestimate the prevalence maternal thoughts of harming their children. It was hypothesized that psychiatrists often do not ask their patients about these thoughts. METHODS: This study surveyed psychiatrists and psychiatric residents at 2 academic institutions. Respondents were asked whether they routinely query women about motherhood, to estimate the frequency of thoughts of child harm, and whether they inquire about filicidal thoughts in psychotic or suicidal mothers. RESULTS: Two hundred twenty surveys (67%) were returned. Most psychiatrists underestimated the frequency of depressed mothers who experienced thoughts of harming their young children. Almost one half indicated that they do not ask specifically about filicidal ideation but rather ask about general homicidal thoughts only. CONCLUSIONS: Psychiatrists should have further education about the prevalence of filicidal thoughts and more frequently inquire about them.     

Community psychiatry and the education of psychiatrists

Opinions vary as to the place in psychiatric education of training for community psychiatry. The confusion is partly due to the assumption that community psychiatry represents a new subspecialty and that therefore training for community psychiatry should follow basic clinical education. With the exception of certain administrative and research aspects, the practices and the knowledge employed by community psychiatrists are becoming part of all effective contemporary psychiatric practice and should be part of the basic education of every psychiatrist. A three-year residency program which coordinates clinical and community psychiatric knowledge and experience is presented. The needs of participants in mental health programs, of teachers and of researchers in community psychiatry, can best be met by specific postgraduate instruction combined with simultaneous job experience.An earlier version of this paper was presented to the staff of the Department of Psychiatry, University of Colorado Medical Center, December 4, 1967.     

What you should know about physical evaluations in psychiatric patients. Results of a survey

Physical illness often initially manifests as a disturbance in thought, behavior, or mood; thus an important aspect of the psychiatric evaluation is differentiating organic disease from "functional" psychiatric disorders. A group of clinically oriented psychiatrists were surveyed about their attitudes and practices regarding medical evaluation in psychiatric patients. Thirty-seven percent of those surveyed performed physical examinations in 60%-100% of their inpatients whereas only 5% performed such examinations on outpatients. Of the 123 respondents, 63 did not perform physical examinations on any of their patients. Twenty-four percent of those who did not perform physicals also did not utilize internists or family practitioners to exclude the possibility of organic disease as a complicating factor in the psychiatric presentation. Those who considered themselves "biologically oriented" were twice as likely to include a physical examination in their inpatient evaluation as those who described themselves as "eclectic" psychiatrists; however, 30% still did no physical examinations in their practice. These findings suggest that though the ability to identify organic illness as a cause for psychiatric symptoms is considered important, psychiatrists often do not utilize the physical examination as a technique in uncovering physical disease.     

Digital psychiatry

The American managed care movement has been viewed as a big experiment and is being watched closely by the rest of the world. In the meanwhile, computer-based information technology (IT) is changing the practice of medicine, much more rapidly than managed care. A New World of digitized knowledge and information has been created. Although literature on IT in psychiatry is largely absent in peer-reviewed psychiatric journals, IT is finding its way into all aspects of medicine, particularly psychiatry. Telepsychiatry programs are becoming very popular. At the same time, medical information sites are flourishing and evolving into a new health-care industry. Patient-physician information asymmetry is decreasing as patients are gaining easy access to medical information hitherto only available to professionals. Thus, psychiatry is facing another paradigm shift, at a time when most attention has been focused on managed care. In this new digital world, knowledge and information are no longer the sole property of professionals. Value will migrate from traditional in-person office-based therapy to digital clinical products, from in-person library search and classroom didactic instruction to interactive on-line searches and distance learning. In this time of value migration, psychiatrists have to determine what their 'distinctive competence' is and where best to add value in the health-care delivery value chain. The authors assess the impact of IT on clinical psychiatry and review how clinical practice, education and research in psychiatry are expected to change in this emerging digital world.     

The private practice study group as phase-IV research tool

Research in the routine field of psychiatry must include psychiatrists in private practice. A majority of psychiatric patients is treated as outpatients and many of these are only seen by private psychiatrists. Setting or patient variables pose restrictions on the therapy which leads to the development of specific treatment strategies. Because these are empirically based, it can be expected that the knowledge of practitioners can make a major contribution to the development of optimal treatment recommendations. Research in private practice requires special organisational efforts. One way to get access to this field are collaborative study groups which bring together scientists and their research facilities with practitioners and their surgeries. Such an instrument may allow: access to patients, which may never show up in any other research institution; monitoring of patient characteristics and treatment modalities under routine conditions; elaboration of special skills, insights and treatment strategies developed by the practitioner. These study groups can vary with regard to type of practice, type of collaboration and type of research. Studies can rely on information from patient self-reports, observations by the practitioners themselves or their office assistants and on data gathered by scientific staff working occasionally or continuously in the practice.     

Do psychogeriatricians 'neglect' religion? An antipodean survey

BACKGROUND: Religion has been found to be important in the lives of many elderly people, but it has been claimed that psychiatrists 'neglect' the religious issues of their patients. This study examines the question: Do psychogeriatricians 'neglect' religion in the assessment and treatment of their patients? METHOD: A sample of 207 psychiatrists with an interest in psychogeriatrics was surveyed using a 14-item questionnaire. Items addressed attitudes and behaviors of psychiatrists towards religion in relation to their clinical practice. RESULTS: Of the 143 (69%) who responded, 43% have no religious affiliation and only 25% participate at least monthly in organized religion. Nevertheless, 85% think that there are links between religion and mental health, and only one respondent stated that psychiatrists should never concern themselves with the religious issues of their patients. A total of 34%, however, had never referred a patient to a pastoral counselor. Training in religious issues is lacking. CONCLUSIONS: Psychogeriatricians think that religion is relevant in the assessment and treatment of elderly patients. In view of the lack of training in religious issues, revisions to the psychiatric training curriculum would be appropriate. This would promote dialogue between psychiatrists and religious caregivers.     

Consumers' views of DSM-III: attitudes and practices of U.S. psychiatrists and 1984 graduating psychiatric residents

The authors surveyed U.S. psychiatrists and psychiatric residents graduating in 1984 about their use and views of DSM-III. Although the majority approved of DSM-III generally, 35% of the psychiatrists and 20% of the residents said they would stop using it if it were not required. Residents accepted DSM-III better than did practicing psychiatrists. Many of the respondents doubted the validity of some diagnoses and stated that many of their patients did not satisfy criteria needed for the DSM-III diagnoses in their records. Most respondents did not use all DSM-III axes and did not want new axes. The authors discuss the survey results and their implications for revision of DSM-III.     

Ethical issues in psychiatric genetics

As knowledge grows regarding the genetic bases of psychiatric disorders, a variety of ethical issues will need to be confronted. Current evidence suggests that the etiology of most psychiatric disorders rests on a combination of multiple genes and environmental factors. As tests for the genes involved become more easily available, pressures will arise to use them for prenatal testing, screening of children and adults, selection of potential adoptees, and pre-marital screening. Common problems that will need to be addressed include popular misunderstanding of the consequences of possessing an affected allele, impact of knowledge of one's genetic make-up on one's sense of self, and the discriminatory use of genetic information to deny persons access to insurance and employment. Although most states have some legislation aimed at preventing discrimination, the laws' coverage is spotty and federal rules are lacking. Physicians may find that newly available genetic information creates new duties for them, including warning third parties who may share the patient's genetic endowment. And genetics research itself has raised questions about when to disclose information to subjects and their family members about the genes that are being studied, and how to define the subjects of the research when information is collected about family members other than the proband. Knowledge of these dilemmas is a first step to resolving them, something that the medical profession will need to attend to in the near-term. Neglect will lead others to set the rules that will control medical practice, including the practice of psychiatry, in the new world of genetic medicine.     

Genetic counseling for psychiatric disorders

Like other medical conditions, some psychiatric disorders are inherited, whereas others are not. Human genetics research is moving at a rapid pace. Genes for over 450 genetic disorders have been cloned and many disease-causing mutations have also been identified. The explosion of this new knowledge has created many new exciting opportunities in the diagnosis of these heritable disorders. The rapid pace of gene discovery will aid the identification of susceptibility genes for psychiatric disorders. Indeed, we can look forward to answers to many clinical and research questions. These are some of the gifts that the expanding field of human genetics research will continue to bring to medical science. However, as genetic tests for the detection of psychiatric disorders become available, many ethical, legal, and social implications will need to be considered. In this article, we review the principles of genetic counseling for psychiatric disorders, as well as the social and ethical dilemmas that genetic testing may bring. Although medical and scientific advances may bring many gifts, we should approach this new knowledge with caution, as one of the gifts may be a Pandora’s box.     

Psychoactive substance use diagnoses among psychiatric in-patients

OBJECTIVE: To estimate the prevalence and possible under-diagnosing of substance use disorders and to consider factors that might influence diagnosing of substance use disorders. METHOD: Data collected from case records and PSE interviews of psychiatric in-patients from 12 psychiatric departments in Denmark admitted during October 1996 were compared with data from the Danish Psychiatric Register. RESULTS: A substantially lower prevalence of substance use diagnoses were found in the register (26.1%) than in the research data (50.0%). A high prevalence of co-occurrence between substance use disorders and mental disorders other than substance use disorders was found (37.3%). In the majority of cases knowledge of the substance use disorders was present in the case records, although they had not resulted in a diagnosis. CONCLUSION: The under-diagnosis of substance use disorders is due not only to concealed diagnostic signs and symptoms but also to an under-diagnosis by the psychiatrists, in spite of the fact that information on the substance use was accessible.     

Clinical decision making in psychiatry by psychiatrists

Bhugra D, Easter A, Mallaris Y, Gupta S. Clinical decision making in psychiatry by psychiatrists. Objective: To derive an in‐depth understanding of the decision‐making process in psychiatry and to explore similarities and differences in psychiatrists’ decision‐making process and the factors that may influence psychiatrists’ decisions. Method: A total of 31 psychiatrists were interviewed on their approaches to decision making in psychiatric practice, using a semistructured interview guide. Framework analysis was undertaken to derive a qualitative understanding of decision making in psychiatry. Results: The analysis generated seven main themes, which collectively influenced the decision‐making process in psychiatry: information gathering, training in psychiatry, intuition and experience, evidence‐based practice, cognitive reasoning, uncontrollable factors and multidisciplinary team influences. Conclusion: No single approach to decision making emerged from the analysis. Approaches to decision making were influenced by the level of clinical experience and external pressures, such as time and treatment availability. Findings were consistent with dual‐processing theory of decision making.     

Incorporating Evidence From Pharmacologic and Pharmacogenetic Studies of Atypical Antipsychotic Drugs Into Advanced Psychiatric Nursing Practice

PURPOSE. To present a conceptual framework for incorporating pharmacologic findings and pharmacogenetic evidence related to atypical antipsychotic drugs (AADs) into advanced psychiatric nursing practice. CONCLUSIONS. Three evidence domains lend important information about differential AAD response. These include the pharmacology of AADs, the molecular genetics of metabolizing enzymes, and the molecular genetics of neurotransmitter receptor drug targets. PRACTICE IMPLICATIONS. These evidence domains can be incorporated into nursing practice decisions related to medication planning, patient and family education, and medication monitoring processes. The central focus of the framework is patient outcomes, which include medication adherence, tolerability of the AADs, and demonstrated clinical effectiveness.