Training needed
To prepare for the emerging advances in genetics and heightened demand for genetic counseling, Finn believes there must be increased educational efforts during medical school and residency training to convey genetic information specific to psychiatry, along with an increased emphasis on genetics in psychiatry in continuing medical education (CME) programs. In the survey of psychiatrists,2 an overwhelming majority (77% to 93%) indicated interest in a variety of educational opportunities about genetics, including CME courses and written and Web-based materials. Finn noted that there is an upcoming article in the Harvard Review of Psychiatry (2007;15[1]) that will discuss education in genetics for residents and propose some curriculum guidelines.
The National Society of Genetic Counselors, according to Finn, is beginning work on practice guidelines for genetic counseling in psychiatry and hopes to collaborate with representatives from the APA on this topic.
In their journal article,1 Finn and Smoller listed several online resources that provide useful information about the genetic basis of a range of disorders including neuropsychiatric conditions. These include GeneTests (www.genetests.org) and Online Mendelian Inheritance in Man (OMIM) (www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=OMIM) Another excellent resource, Finn said, is the Web site of the National Coalition for Health Professional Education in Genetics (NCHPEG) (www.nchpeg.org) of which the APA is a member. Psychiatrists, Finn said, can find on the site an online version of the CD-ROM, "Genetics and Major Psychiatric Disorders," and other educational materials on psychiatric genetics. The tutorial reviews the genetic basis of major psychiatric disorders, describes genetic conditions that may present with psychiatric symptoms, provides recent research updates in the field of psychiatric genetics, and outlines issues in genetic counseling for psychiatric disorders. NCHPEG's Content and Instruction Working Group also is working on a project focusing on genetics in bipolar disorder.
Elements of genetic
counseling sessions
Finn and Smoller,1 in their review article, describe the indications for and suggested elements of psychiatric genetic counseling sessions. At a minimum, the session should include gathering information (purpose of the consultation, individual and family histories, and evaluation of capacity of the client to participate in consultation); conveying information (estimations of recurrence risk based on family history and empiric risk data; general information regarding psychiatric illness,
available treatments, and options for
support); exploring the consultant's understanding of the information; facilitating decision making and providing support; and following up (in person or in writing).
"This is a complex process and not something you can squeeze into a couple of minutes' conversation with your patient," Finn said, adding that it is a process that deserves a lot of time, thought, preparation, and often collaboration with genetics professionals. These consultations often take her about an hour and a half to 2 hours and another hour of documentation, she said, and reimbursement can be a problem.
"Reimbursement has come up almost every time I have done one of these consultations. If I put it under genetics, it is more straightforward, but if I try to do it as a psychiatrist, there really isn't a good CPT code to reflect what I am doing," she said. The reimbursement issue is even more challenging when the client does not have a diagnosed psychiatric disorder but is at risk for one.
"As we move to a model in general in medicine where we hope to be providing more preventive care, there needs to be a shift in the way we can bill for services," she added.
Patients who have questions beyond the knowledge base of their psychiatrist can be referred to the National Society of Genetic Counselors. (www.nsgc.org), which allows individuals to search for genetic counselors based on location and areas of specialization; to GeneTests; or to a department of genetics at a major medical center.
"Overall," Finn added, "it is an exciting time to be in psychiatry and to have an additional tool to help us understand psychiatric disorders and . . . to help us think about new treatment opportunities and prevention strategies."
