Trustees Tackle Wide Range of Controversial Issues

Back to table of contents Previous article Next article Legal NewsFull AccessAPA Calls for Halt to Executions Of Mentally Incompetent ConvictsAaron LevinAaron LevinPublished Online:20 Jan 2006https://doi.org/10.1176/pn.41.2.0013aMentally impaired defendants and prisoners convicted of capital crimes but later found to be mentally incompetent should not be executed or sentenced to death, according to two position statements approved by the APA Board of Trustees at its December 2005 meeting.Death row prisoners who lack the capacity to make rational decisions about pursuit of postconviction appeals, to assist legal counsel during those proceedings, or to appreciate the meaning or purpose of their impending execution should not be executed, said the first statement.Just how many prisoners meet any of the above criteria is unknown, said Paul Appelbaum, M.D., chair of APA's Council on Psychiatry and Law and a former APA president. A defendant in a capital case would have to have been competent to stand trial, convicted but not found not guilty by reason of insanity, and found mentally incompetent only after being sentenced to death. However, that is not as unlikely as it sounds, said Appelbaum, a professor of psychiatry at Columbia University and a leading forensic psychiatrist."Many people pass through all those screens and have the death penalty imposed and only then are recognized as having serious mental illnesses," he said in an interview. "Formal findings of incompetence at some point in the process are not all that common, especially with regard to competence to be executed. But a larger percentage of persons on death row appear to have significant mental disorders. It may be a failing of the current system that findings of incompetence are as uncommon as they are."Full Participation NeededThe Supreme Court has said that mentally competent prisoners may choose to forego appeals of the death penalty and that action is not in itself evidence of incompetence (Gilmore v. Utah, 429 U.S. 1012[1977]). Since a prisoner's full participation is needed to assure fair resolution of postconviction claims, he or she must be competent to assist counsel in those proceedings. Current procedure allows a third party, a "next friend," to pursue appeals or other proceedings on behalf of an incompetent prisoner. The new statement advocates that such a person step in when the prisoner has a mental disability or disorder "that significantly impairs his or her capacity to make a rational decision.""Any impediment to thorough collateral review undermines the integrity of the review process and therefore of the death penalty itself," according to the American Bar Association (ABA). "The possibility, however slim, that incompetent individuals may not be able to assist counsel in reconstructing a viable factual or legal claim requires that executions be barred under these circumstances."Current ABA standards say that court proceedings must stop and no execution take place if prisoners lack the capacity to assist their lawyers. Such cessation would become permanent if a judge finds that the prisoner is unlikely to return to competence in the "foreseeable" future. In those cases, according to the APA statement, the death sentence should be automatically reduced to a lesser punishment.The third point in the APA statement requires that a prisoner must not only understand the nature and purpose of the punishment but also why it is being imposed: "Offenders should have more than a shallow understanding of why they are being executed."APA's position advocates commuting to life imprisonment the death sentences of persons found incompetent to be executed. That step would obviate the ethical dilemma arising when courts order such prisoners to be treated to restore competence and permit execution."Treatment for the purpose of restoring competence to be executed is unethical," said Appelbaum, although the Supreme Court has not found a constitutional obstacle to treatment in such circumstances. APA has not formally endorsed commutation to a life sentence in such cases, but both APA and the AMA in amicus briefs have sought to avoid an ethically impossible choice between execution and untreated psychosis. Commutation would permit treatment of a severely psychotic prisoner without raising this ethical conflict, said Appelbaum.Other Impairments Should Be WeighedThe Board also authorized a second statement urging courts to reject the death penalty for additional categories of defendants with significantly impaired mental capacity."Defendants should not be executed or sentenced to death if, at the time of the offense, they had significant limitations in both their intellectual functioning and adaptive behavior, as expressed in conceptual, social, and practical adaptive skills, resulting from mental retardation, dementia, or a traumatic brain injury," said the statement.If adopted by the judicial system, the statement would extend the Supreme Court's 2002 judgment in Atkins v. Virginia, ruling out the death penalty for mentally retarded individuals, to two other disorders involving equivalent levels of impairment.Adopting the current statements marks another step in coordinating APA views on death penalty issues with other mental health and legal organizations. APA cooperates with the ABA, American Psychological Association, and National Alliance on Mental Illness in finding common ground on application of the death penalty to people with mental illness."Our hope is that if four of the major groups in the U.S. that are concerned with law and mental health align their views, it will carry substantial weight, not so much with the courts, but with legislatures who can enact these policies into law," said Appelbaum.The position statements will be accessible shortly at<www.psych.org/public_info/libr_publ/position.cfm>.▪ ISSUES NewArchived

Pharmacological treatments for certain psychiatric disorders in young people are often ineffective and may cause major side effects; thus, it is important to investigate other treatments. This article reviews the literature on the efficacy and safety of ECT in this age group and examines the evidence for the suggestion that it may be used inappropriately. All studies published in English and other languages on the use of ECT in persons 18 years of age or younger were obtained. The reports were systematically reviewed and rated according to the quality of the information in several domains, yielding an overall quality score for each study. Individual cases from each report were then examined and grouped according to diagnosis and response to ECT. Sixty reports describing ECT in 396 patients were identified; most (63%) were single case reports. The overall quality was poor but improved in the more recent studies. There were no controlled trials. Rates of improvement across studies were 63% for depression, 80% for mania, 42% for schizophrenia, and 80% for catatonia. Serious complications were very rare, whereas minor, transient side effects appeared common. ECT in the young seems similar in effectiveness and side effects to ECT in adults. However, this conclusion is qualified by the lack of systematic evidence. More research and education of professionals and the public are needed. It is suggested that ECT registers be set up, that surveys and controlled trials be conducted, and that seizure thresholds, the optimal anesthetic, effects of concurrent medications, and cognitive consequences of ECT in the young be investigated.

The author describes an occurrence of ECT-induced status epilepticus in a patient who was psychotically depressed and unresponsive to tricyclic and neuroleptic medication. After an extensive evaluation and further unsuccessful use of treatment alternatives the patient then received a course of specially modified ECT; he had no further sequelae and had a good clinical response.

Back to table of contents Previous article Next article ArticleNo AccessAPA's Stand on the Insanity DefenseJOHN RACYJOHN RACYSearch for more papers by this authorPublished Online:1 Apr 2006https://doi.org/10.1176/ajp.141.3.466AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail "APA's Stand on the Insanity Defense." American Journal of Psychiatry, 141(3), p. 466 Access content To read the fulltext, please use one of the options below to sign in or purchase access. Personal login Institutional Login Sign in via OpenAthens Purchase Save for later Item saved, go to cart PPV Articles - American Journal of Psychiatry $35.00 Add to cart PPV Articles - American Journal of Psychiatry Checkout Please login/register if you wish to pair your device and check access availability. Not a subscriber? Subscribe Now / Learn More PsychiatryOnline subscription options offer access to the DSM-5 library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development. Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.). FiguresReferencesCited byDetailsCited byNone Volume 141Issue 3 March 1984Pages 466-466 Metrics PDF download History Published online 1 April 2006 Published in print 1 March 1984

The authors evaluated characteristics of patients whom clinicians accurately assessed as being at high or low risk for violence and patients for whom clinicians overestimated or underestimated the risk. At admission, physicians estimated the probability that each of 226 psychiatric inpatients would physically attack someone during the first week of hospitalization. Nurses rated assaultive behavior in the hospital with the Overt Aggression Scale. Acute symptoms were rated with the Brief Psychiatric Rating Scale. For the group as a whole, assessed levels of risk were substantially related to later physical aggression (sensitivity = 67%, specificity = 69%). Multinomial logit analysis showed that patients with psychotic disorders such as schizophrenia, organic psychotic conditions, and mania were more likely to be accurately assessed by clinicians as being at high risk (true positives) than to be true negatives or false positives. A recent history of violence was associated with higher estimated risk but did not distinguish true positives from false positives. An admission mental status characterized by low levels of hostility, uncooperativeness, and suspiciousness and high levels of depression, guilt, and anxiety differentiated true negative patients from others, but symptom profiles did not differ among true positives, false positives, and false negatives. Clinical judgments emphasizing gender and race/ethnicity were associated with predictive errors: nonwhite and male patients tended to be false positives. While clinicians can accurately classify the potential for violence in the majority of patients at admission, systematic errors characterize inaccurate assessments of the risk. Awareness of these patterns may help improve assessment of the risk of violence in clinical practice.

In Brief Objective The objective of this study was to determine whether United States medical or osteopathic boards have opinions, position statements, or policies on chaperone use, and whether any state laws regulate chaperone use. Methods United States Medical and Osteopathic Boards were surveyed by mail to determine whether policies, opinions, positions, or laws exist regarding use of chaperones during gynecologic examinations. We sent the survey to executives at 67 state boards, identified by a list from The Federation of State Medical Boards. Our main outcome measure was positive response to the survey questions. Results Of 67 targeted sites, 61 responded (91%). Fourteen sites (23%) reported having informal or unpublished opinions recommending chaperones. Eleven sites (18%) reported having positions related to chaperones that have been published for their physicians. Four sites (6.5%) reported having policies specifically related to chaperone use. Thirty-two sites (52.5%) reported that they do not have opinions, positions, or policies related to chaperone use. No site reported state laws governing chaperone use. Conclusion Response to our survey showed no concensus among state medical boards on the use of chaperones, leaving doctors and patients to decide for themselves whether they want or need chaperones present during gynecologic examinations. Medical boards lack uniformity in providing guidance for physicians on chaperone use.

PROMPTED BY GROWING EVIDENCE that pregnant women face a higher risk of fetal problems both with the use of selective serotonin reuptake inhibitors (SSRIs) and with untreated depression, experts from the American College of Obstetricians and Gynecologists (ACOG) and the American Psychiatric Association (APA) are offering physicians a nuanced set of guidelines that emphasize an individualized approach. Between 10% and 20% of women experience depression during pregnancy, according to the March of Dimes, and the use of antidepressant medications in this population for at least some period during pregnancy more than doubled in recent years, from 5.7% of pregnancies in 1993 to 13.4% in 2003 (Cooper WO et al. Am J Obstet Gynecol. 2007;196[6]:544e). Yet even as more women and their physicians recognize the importance of treating depression for the wellbeing of both mother and child, they face difficult choices when considering whether medicat ion use is appropriate. Recent data suggest that use of SSRIs, which are now the most commonly used antidepressants, during pregnancy may contribute to an increased risk of such outcomes as septal heart defects, preterm delivery, low 5-minute Apgar score, and admission to a neonatal intensive care unit. These new findings add to a complex body of evidence that has linked both antidepressant use and gestational depression with poor fetal growth, premature delivery, and short-term behavioral changes in the neonate, according to a recent review and guidelines by the APA and ACOG (Yonkers KA et al. Gen Hosp Psychiatry. 2009;31[5]:403-413). Other studies have suggested that SSRI use during early pregnancy is associated

Back to table of contents Previous article ArticleNo AccessPosition Statement on Support for Psychiatric ResearchPublished Online:1 Apr 2006https://doi.org/10.1176/ajp.134.5.612AboutSectionsView articleAbstractPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View articleAbstractThis statement was approved by the Assembly of District Branches at its October 29-31, 1976, meeting and by the Board of Trustees at its December 10-11, 1976, meeting, upon recommendation of the Council on Research and Development. It was prepared by the Council on Research and Development.1 Access content To read the fulltext, please use one of the options below to sign in or purchase access. Personal login Institutional Login Sign in via OpenAthens Purchase Save for later Item saved, go to cart PPV Articles - American Journal of Psychiatry $35.00 Add to cart PPV Articles - American Journal of Psychiatry Checkout Please login/register if you wish to pair your device and check access availability. Not a subscriber? Subscribe Now / Learn More PsychiatryOnline subscription options offer access to the DSM-5 library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development. Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.). FiguresReferencesCited byDetailsCited by Volume 134Issue 5 May 1977Pages 612-612 Metrics PDF download History Published online 1 April 2006 Published in print 1 May 1977

Back to table of contents Previous article Next article ArticleNo AccessPosition Statement on the Quality of LifePublished Online:1 Apr 2006https://doi.org/10.1176/ajp.133.5.603AboutSectionsView articleAbstractPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View articleAbstractThis statement was approved by the Board of Trustees at its December 5-6, 1975, meeting upon recommendation of the Council on National Affairs. it was prepared by the Task Force on Ecopsychiatric Data Base.1 Access content To read the fulltext, please use one of the options below to sign in or purchase access. Personal login Institutional Login Sign in via OpenAthens Purchase Save for later Item saved, go to cart PPV Articles - American Journal of Psychiatry $35.00 Add to cart PPV Articles - American Journal of Psychiatry Checkout Please login/register if you wish to pair your device and check access availability. Not a subscriber? Subscribe Now / Learn More PsychiatryOnline subscription options offer access to the DSM-5 library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development. Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.). FiguresReferencesCited byDetailsCited byNone Volume 133Issue 5 May 1976Pages 603-603 Metrics PDF download History Published online 1 April 2006 Published in print 1 May 1976

Back to table of contents Previous article Next article Letters to the EditorFull AccessASAP's Role RecognizedMark A. Wellek, M.D., Mark A. WellekSearch for more papers by this author, M.D., Past PresidentPublished Online:17 Jun 2005https://doi.org/10.1176/pn.40.12.00400038Thank you for the article in the April 5 issue on the successful fight against the juvenile death penalty in the Supreme Court case Donald Roper v. Christopher Simmons (“Court Bars Death Penalty for Youth Under Age 18”). The article noted how APA and the American Academy of Child and Adolescent Psychiatry (AACAP) signed onto a brief in the case submitted to the Supreme Court. I would like to point out the actions of a prime and early mover on the issue, the American Society for Adolescent Psychiatry (ASAP).In 1986 ASAP initiated and sponsored the original psychiatric argument in its amicus curiae brief in the case Thompson v. Oklahoma. At the time, ASAP was the only organization to sign on to an amicus brief concerning adolescent development. That brief was repeatedly referenced in the Supreme Court's decision in 1988 to strike down the death penalty for capital crimes committed by children and adolescents below the age of 16.I was also active within APA on this issue, and I was instrumental in bringing the issue to the Council on Children, Adolescents, and Their Families. In 2001 the council referred AACAP's position statement opposing the juvenile death penalty to APA's Joint Reference Committee (JRC) for possible adoption by APA. The JRC referred the statement to the Council on Psychiatry and Law, which revised it. The statement was subsequently approved by the Assembly in May 2001 and by the Board of Trustees a month later.In that same timeframe, ASAP joined with the Juvenile Death Penalty Initiative of the American Bar Association and one of its able leaders, attorney Stephen Harper. We wrote letters under the auspices of our respective organizations to the governors of Texas, Oklahoma, Missouri, and Kentucky asking them to commute the death sentences of adolescent offenders. We had some success and helped to slow and even to prevent some executions. Subsequently I testified on adolescent brain development before the South Dakota legislature. In March 2004, Gov. Michael Rounds signed a law raising the age of eligibility for the death penalty to 18.Finally, in 2003 ASAP initiated another amicus brief, and APA's Board of Trustees voted to sign on in June 2004. Dr. Robert Weinstock, the current president of ASAP and a member of APA's Committee on Judicial Action, played a key role in revising the language to improve it.A summary of the brief's arguments states, “The adolescent's mind works differently from ours.... Scientists have documented the differences along several dimensions. Adolescents as a group, even at the age of 16 or 17, are more impulsive than adults. They underestimate risks and overvalue short-term benefits. They are more susceptible to stress, more emotionally volatile, and less capable of controlling their emotions than adults.“In short, the average adolescent cannot be expected to act with the same control or foresight as a mature adult.”This brief is now history, and we in ASAP feel a strong sense of pride as part of the large coalition of professional and advocacy groups that worked together to end the execution of juvenile offenders in the United States.American Society for Adolescent Psychiatry ISSUES NewArchived

In 1975, sweeping changes were made in the procedures for dealing with insanity defenses in Michigan. The effects of these changes are examined by a comparison of the populations of insanity acquittees before and after 1975. The results reveal that there has been a nonsignificant increase in total number of insanity acquittals since 1975. However, there has been a significant change in the distribution of crimes for which defendants have been found insane. Specifically, the number of insanity acquittals for homicide has decreased, while the number for less serious offenses has increased. Possible explanations for these findings are explored.

Background: violence risk assessment in persons acquitted by reason of insanity is difficult. It seems appropriate to consider the possibilities of psychological assessment based on the biopsychosocial model in addition to clinical ones. Standard survey methods do not provide sufficient information. The schema therapy approach is proposed as an alternative. The Aim of study was to assess violence risk in patients under compulsory treatment using new instruments for psychological examination. Patients: 137 male patients aged 18–62 years (М = 37.03; SD = 9.65) under compulsory treatment. Methods: author's scale, Young Shema Questionnaire, Schema Mode Inventory, Historical Clinical Risk Management-20. Results: patients are characterized by violence risk factors (overall scale: M = 19.57; SD = 7.92; Me = 19). Anamnestic factors (M = 10.89; SD = 3.65; Me = 11) and risk management factors (M = 5.25; SD = 2.78; Me = 5) prevailed over clinical ones (M = 3.43; SD = 2.52; Me = 3). The relationships shown: a) «Lack of self-control» with the overall score of violence risk (rs = 0.331; p ≤ 0.001) and its clinical signs (rs = 0.328; p ≤ 0.001); b) «Distrust» with the overall score also (rs = 0.304; p ≤ 0.001) and its anamnestic signs (rs = 0.311; p ≤ 0.001). The greatest contribution to the degree of violence risk is made by the schemes and modes: “Negativism/pessimism” (β = 0.573; p ≤ 0.001), “Failure” (β = 0.331; p ≤ 0.01), “Detached self-consoler” (β = −2.165; p ≤ 0.001), “Enraged child” (β = 3.327; p ≤ 0.001), “Angry child” (β = −2.430; p ≤ 0.05). Conclusions: severity of schemes and modes indices can play an important role in predicting relapse of socially dangerous act. This methods can be used to assess the violence risk severity as an additional one.

Comments on the APA Position Statement on Psychoactive Substance Abuse and Dependence: Update on Marijuana and Cocaine

Comment on the APA position statement on psychoactive substance use.

Approximately 10% to 16% of women meet diagnostic criteria for depression during pregnancy. Untreated maternal depression is associated with adverse pregnancy outcomes including premature birth, low birth weight, and fetal growth restriction. The aim of this study is to review the current safety data on electroconvulsive therapy (ECT) in pregnancy and provide guidance to clinicians on the role of ECT in pregnancy and the special considerations for its use in our population. We reviewed 4 meta-analyses on the use of ECT in pregnancy as well as the source material (case series, etc) for these meta-analyses. We reviewed the official position statements on ECT in pregnancy from obstetric and psychiatric governing bodies as well as clinical best practice information from practitioners of ECT in pregnancy. Electroconvulsive therapy may be underutilized due to stigma and lack of access for these women. Rates of ECT use in pregnancy are difficult to determine. There are physiologic differences in pregnancy that merit additional attention during ECT, including increased risk of aspiration, concern for aortocaval compression, and the possibility of fetal heart rate changes associated with prolonged seizure activity. Serious adverse outcomes associated with ECT use in pregnancy are rare. Electroconvulsive therapy is a highly effective and safe treatment modality for unipolar depression, bipolar disorder, schizophrenia, and other psychiatric illnesses. Electroconvulsive therapy treatment in pregnancy requires a multidisciplinary team approach with obstetrics, maternal-fetal medicine, psychiatry, and anesthesiology, but is overall felt to be safe and effective.