Intellectual Jujitsu. Respectful debates about substantive topics are signs of curiosity and imagination signaling health of mind—or in this case the community of minds that is psychiatry. True controversies, such as those examined here, are substantive clinical issues about which there is real and serious disagreement among experts. Strong evidence supports sound arguments on each side of each topic. This Special Report collection, chaired by Dr. Cynthia Geppert, looks at 3 controversies in psychiatry: (1) the pros and cons of assisted outpatient treatment; (2) forced medication; and (3) antidepressant use in pregnancy. Neuroscience has more than proved that engaging in challenging mental exercise is key to the longevity and vitality of the life of the mind. So we invite readers to join us in this age-old intellectual jujitsu, which has been an essential part of the training of rabbis and lawyers, philosophers, and—yes—physicians. See Dr. Geppert's introduction: Deep Dives and Intellectual Jujitsu
Controversy 1. AOT, Going mainstream. After lounging on the doorstep of respectability for the past decade, assisted outpatient treatment (AOT) has finally entered the mainstream. E. Fuller Torrey, MD and John D. Snook, JD dispel common misconceptions about AOT and they address arguments against it. For example, one source of AOT opposition is concerns about coercion or a restriction of individual liberties. AOT serves as a lightning rod for opposition to all forms of involuntary psychiatric treatment, despite AOT being no more coercive than conditional release or mental health courts—both of which are widely accepted. AOT is here to stay, not as a cure-all but rather as another tool to help selected patients who are otherwise the most difficult to help. See: Assisted Outpatient Treatment Enters the Mainstream
SIGNIFICANCE FOR THE PRACTICING PSYCHIATRIST: AOT is court-supervised treatment of severe mental illness within the community. It is a 2-way commitment that requires mental health systems to serve participants at the same time it commits participants to adhere to their treatment plans. It is similar in intent to conditional release, mental health courts, and conservatorship—all of which seek to improve the person’s adherence to a treatment plan and quality of life. AOT has been proven to be especially effective in reducing rehospitalization, arrests, and violent behavior. For a mobile-friendly view of the monarch notes, click here.
The specific procedures vary by state, but generally, to be a candidate for AOT, a person must meet clinical and legal criteria, such as a history of repeated hospitalizations or arrest resulting from nonadherence to treatment. For example, in New York the person must, among other factors, have a history of treatment nonadherence that has led to 2 or more psychiatric hospitalizations or incarcerations within the past 3 years or 1 or more acts of serious violence in the past 4 years; be unlikely to voluntarily participate in outpatient treatment; and be in need of treatment to prevent a relapse that would likely result in serious harm to self or others. Court petitions for AOT are usually filed by the county mental health department, which also arranges for development of a treatment plan and delivery of services. The figure provides a visual for how assisted outpatient treatment enters the mainstream. For a mobile-friendly view of the figure, click here.
Controversy 2: When is forced medication okay? Is it ever okay? The authors examine legal and ethical challenges for psychiatrists and provide tips for determining when involuntary medication is appropriate for patients who are deemed incompetent to stand trial. They include treatment-related assessment in the context of the patient’s case, intervention administration and medically appropriate care, and follow-up concerns, treatment plans, and restoration maintenance considerations. See: Forced Medication and Competency to Stand Trial: Clinical, Legal, and Ethical Issues.
SIGNIFICANCE FOR THE PRACTICING PSYCHIATRIST: The treatment of psychiatric disorders in people who are incompetent to stand trial and who decline to take prescribed psychotropic medication presents legal and ethical challenges for the practicing psychiatrist. Competency to stand trial is one of several competency issues within the criminal law. A series of cases decided by the US Supreme Court provides guidance on several circumstances in which a patient incompetent for trial may be involuntarily medicated. For a mobile-friendly view of the monarch notes, click here.
Controversy 3: Baby with SSRIs on board? By dissecting guidelines and new research, clinicians can assist patients in making informed treatment decisions. This article discusses the risks and the benefits of both in utero antidepressant exposure and untreated maternal psychiatric illness, and it outlines a clinical approach to designing a treatment strategy during pregnancy. See: Antidepressants in Pregnancy: Balancing Needs and Risks in Clinical Practice
SIGNIFICANCE FOR THE PRACTICING PSYCHIATRIST: The literature on the safety of in utero antidepressant exposure is large, robust, and often contradictory. Because many studies are small, retrospective, and observational, it is not uncommon for studies of the same risks and outcomes to have findings that directly contradict one another. Further, several well-controlled studies suggest the previously identified associations with antidepressant exposure may be secondary to differences in the psychiatric population For a mobile-friendly view of the monarch notes, click here.
Ms Timoshin is Executive Editor of Psychiatric Times.