Miscellaneous As of 31Jul06

Suicide assessment Q. What is the value of a suicide assessment? Do such assessment’s have a high predictive level?

Suicide assessment. Ans. Not a reliable predictor of suicide, but are of value as to what questions to ask. Suicide Practice Guideline, AJP Supplement, November 2003

Protective as to suicide Q. The Practice Guideline on suicide list ten items that are relatively protective. List them.

Protective as to suicide - 1 Ans. [We all know exceptions, but the following tends to be statistically true.] 1.Children in the home 2.Sense of responsibility to family 3.Pregnant 4.Religiosity 5.Life satisfaction 6.See next slide

Protective as to suicide Reality testing ability 7. Positive coping skills 8. Positive problem-solving skills 9. Positive social skills 10. Positive therapeutic relationship. [Note that #1 and #3 are ripe for exam questions.]

Risk per disorder Q. While “prior suicide attempt” is riskier than any Disorder, which disorder has the highest rate of suicides?

Risk per disorder Ans. Eating Disorder has the highest rate, just ahead of MDD.

Low rate Q. All disorders have a higher rate than the general population -- except which Disorder?

Low risk Ans. MR pts have a lower rate than the general population.

Med that reduces suicides Q. Which med has the strongest evidence of reducing suicides?

Med that reduces suicides Ans. Li

Anticonvulsants Q. What about anticonvulsants that are regarded as mood stabilizers? Can they reduce suicide?

Anticonvulsants Ans. No evidence they decrease the risk of suicide.

FDA Q. Which, if any med, has FDA approval for reducing the risk of suicides?

FDA Ans. Clozapine when used with people who have schizophrenia.

ECT Q. ECT any help in reducing suicide?

ECT Ans. Practice guideline say yes, “at least in the short term.”

Psychosocial approaches Q. Do psychosocial approaches reduce risk of suicide?

Psychosocial approaches Ans. CBT and DBT both have studies suggesting they are effective. [Probably no exam question will assume that psychosocial approaches are not helpful.]

Documentation Q. Role of documentation?

Documentation Ans. While suicide risk is not predictable, any exam question will expect considerable reverence for thorough documentation of the risk – partially for legal protection should the pt suicide. Restated, good documentation that you explored and weighed the risks reduces your legal risks.

Suicide contracts Q. Value of suicide contracts?

Suicide contracts Ans. Not recommended in ER, or when pt is agitated, psychotic, impulsive, or under the influence.

Communications with others Q. What to do if pt seems very suicidal and refuses to let you speak to his wife or anyone else?

Communications with others Ans. “The psychiatrist is justified in attenuating confidentiality to the extent needed to address the safety of the pt.”

Post-suicide communications Q. Your pt has suicided? What to tell his family? What not to tell?

Post-suicide communications Ans. In allaying grief and, if indicated, helping family members, you should avoid: -- revealing confidential info -- avoid self-incriminating statements -- avoid self-exonerating statements

Hendricks v. Kansas Q. Hendricks v. Kansas applied to what?

Hendricks v. Kansas Ans. Supreme Court decision that endorsed Kansas policy to transfer dangerous sex offenders to psychiatric hospitals on expiration of their prison sentence. {117 S. Ct (1997)}

Ethics question – romantic/sexual relationships Q. Are there any circumstances in which it would be ethically OK to have a relationship with a psychiatric resident? {These ethical questions are taken from the APA ethical opinions.}

Ethical question – romantic/sexual relationship Ans. Not in your program, but OK to have a relationship with a resident in another program in which you have no role.

Pt and supervisee Q. You have a social worker as a pt. She would like for you to supervise her clinical work. Would that be ethical?

Pt and supervisee Ans. No. Constitutes a potential exploitation as well as confusion of the therapeutic relationship.

Pt and employee Q. You have an unemployed pt who has skills that your office could use. It is ethical to hire him?

Pt and employee Ans. It is not ethical to switch a physician-pt relationship to an employer-employee relationship.

Confidentiality after death Q. Your patient has died after a long history of schizophrenia and lung cancer. It is OK to provide confidential information to members of his family who would like to know more about his life?

Confidentiality after death Ans. No. Ethical rules of confidentiality still apply.

Bequeath estate Q. Your pt of 20 years is dying of ovarian cancer. She has no family and wants to leave her estate of several thousand dollars to you as you’ve been invaluable to her over the past two decades. OK?

Bequeath estate Ans. No. OK to give to a charity whose goals might be the same as yours.

INS & homosexuality Q. In an INS investigation, is it ethical for a psychiatrist to certify that an immigrant is homosexual when that determination will result in exclusion of the person from the US?

INS & homosexuality Ans. No. A psychiatrist should not be party to any type of policy that excludes, segregates, or demeans the dignity of any pt because of ethnic origin, race, creed, age, socioeconomic status, or sexual orientation.

Missed appointments Q. Is it ethical to charge for missed appointments?

Missed appointments Ans. Yes, if part of the treatment contract.

Unaware Q. A pt with limited resources pays a small fee for seeing you, unaware that her mother pays the remainder of your usual fee. Ethical?

Unaware Ans. No. Physicians must be honest with their pts.

Christian psychotherapy Q. Is it proper to practice Christian Psychotherapy, a psychotherapy that may take fundamentalist positions on homosexuality, abortion, sex outside the marriage, and failure to pray causes illnesses?

Christian psychotherapy Ans. OK, if pt fully informed and still seeks the Christian psychotherapy.

Can’t manage competently Q. You are working at a hospital that requires you to assume more responsibility than time or resources allows you to manage your pts competently. Ethical to continue under those circumstances?

Can’t manage competently Ans. You can continue to work under those conditions if you are advocating to the hospital leadership the need for additional resources. Otherwise, you should resign.

Solicit money Q. You are working for a university in their clinic, and you are asked to solicit money from your wealthy ex-pts for a research program on schizophrenia. Is this ethical?

Solicit money Ans. Not ethical to exploit even ex-pts for a research program from which the pts will not directly benefit.

Proportion of the fee Q. In your town, there is a major law firm that refers out NQBRI cases to local psychiatrists. Is it ethical for you to have an understanding with them that, for each case that is sent to you, you will give them a $100?

Proportion of the fee Ans. No, that is fee splitting.

Adopt Q. As a child psychiatrist, you are responsible for a hospital unit of 12 children. One of the children has recently had both parents killed in an auto accident, and there are no other relatives available. You and your significant other would like to adopt the child. Ethical?

Adopt Ans. No, as that is seen as exploiting the therapeutic relationship. Further, the impact on the other pts on the ward would likely be negative.

Clozapine program Q. As director of the state’s only public mental hospital, for pts with chronic schizophrenia, it is ethical to limit voluntary admissions to pts who will agree to be admitted to a clozapine program?

Clozapine program Ans. Not ethical unless the state has another program with equivalent services to which the chronically ill with schizophrenia can volunteer.

LEP Q. Do you have an ethical obligation to use interpreters when dealing with pts of limited English proficiency?

LEP Ans. To the extent possible, a psychiatrist should arrange to use interpreters when dealing with LEP pts so that the pts can communicate effectively, especially as to being able to provide informed consent.

Change sexual orientation Q. Is it ethical to engage in a therapy [such as reparative or conversion therapy] to change the pt’s homosexual to heterosexual orientation when the pt has asked for such?

Change sexual orientation Ans. No. Any treatment based on an assumption that homosexuality per se is a mental disorder is unethical.

Parent Q. You are treating with some success a nine year old boy. His mother, long divorced, and you are both becoming attracted to each other. OK to have a romance with her?

Parent Ans. No

Phone charges Q. Is it ethical for you to charge for telephone calls from your pts?

Phone charges Ans. Yes, if part of the treatment contract.

Sexually attracted Q. What to do if you become sexually attractive to a pt?

Sexually attracted Ans. I think the exam-question writers will be satisfied if you will get a personal consultation