AMA Acts on Critical Psychiatry-Related Issues

The dearth of psychiatric inpatient beds and its dire effect on emergency departments nationwide captured the attention of AMA delegates at this year's annual policymaking meeting of the AMA House of Delegates last month.

Physicians in a variety of specialties testified to a “crisis” in the number of acutely ill psychiatric patients filling the waiting rooms of general emergency departments across the country.

“The reality is that there is a shortage of inpatient psychiatric beds, and this is having an effect not only on patients but on medical services in the emergency department and throughout the hospital,” said John McIntyre, M.D., chair of the APA Section Council on Psychiatry.

In response to that testimony, delegates approved a resolution requesting that the AMA work with APA and other organizations to develop recommendations regarding the scope of the problem of psychiatric-bed availability and its impact on the nation's emergency and general medicine resources.

The resolution was one of many issues either brought directly by the Section Council on Psychiatry or by other delegations but of import to psychiatry at this year's meeting. These issues included use of SSRIs during pregnancy, psychosocial impact of video games on young people, pharmacists' refusal to fill prescriptions, and physician involvement in execution.

The house also considered an item brought by the Section Council on Psychiatry on availability of health care, including mental health care, to veterans returning from Iraq and Afghanistan (see Original article: AMA Gears Up for Report on Vets).

Anthony Jaspers, M.D., a physician from Minnesota, testified during reference committee hearings that psychiatric care is “a crisis” in his state and many others.

“I have personally dealt with the lack of psychiatric beds in our community,” he said. “I have a son who is bipolar, decompensated, and had to be admitted to the psychiatric hospital 75 miles away because our community hospital had no psychiatric beds available.”

Linda Lawrence, M.D., president of the American College of Emergency Physicians, said this is “an extremely important issue that the AMA cannot ignore.”

Video Gaming an Addiction?

An issue that attracted enormous press coverage was the AMA's attention to the possibly detrimental psychosocial effects of video and Internet games on young people.

An AMA Council on Science and Public Health report was approved by the house requesting that the Centers for Disease Contol and Prevention, National Science Foundation, and National Institutes of Health fund research on the long-term beneficial and detrimental effects of playing video games and for the determination of a “scientifically based guideline for total daily or weekly screen time.”

The council also asked that its report be forwarded to APA for consideration for the next edition of DSM.

Some controversy and misinformation, emerged around the council report regarding an original recommendation that young people be limited to one to two hours of viewing a day and around erroneous reports in some media outlets that the AMA had “directed” APA to include a diagnosis concerning video game addiction in the next DSM.

Child psychiatrist and APA Trustee David Fassler, M.D., a member of the section council, spoke to the latter issue, noting that the reports in the media were false.

“We don't want the AMA or any other organization lobbying or advocating for or against specific diagnoses,” he said. “APA is beginning an extensive five-year process to revise DSM, which will involve a careful review of the research on all psychiatric disorders. This is a process that involves several hundred clinicians and researchers organized in specific work groups.”

But he said the report underscored a critical issue. “There's a growing body of research in this area, and a number of studies have indicated an increase in aggressive behavior following exposure to media, including video games, that depict violent themes. Research has also shown that the more realistic and repeated the exposure, the greater the impact.”

Psychiatrist and addiction specialist Stuart Gitlow, M.D., among other addiction experts, testified that the science was not developed enough to justify designating video game playing an “addiction” or to merit a specific time limit on viewing.

Pharmacy Refusals Raise Concern

The house also approved without debate a resolution, written by APA President-elect Nada Stotland, M.D., that directs the AMA to prepare a report summarizing the available information regarding delays or difficulties patients have experienced due to pharmacists' refusal to fill valid prescriptions and to develop recommendations to ensure that patients' prescriptions are filled in a timely manner.

“State laws allowing pharmacists to refuse to prescribe medications that are legally prescribed by physicians but to which the pharmacist has objections of conscience often include the qualification that the patient who has been refused his or her medication be referred to another pharmacy for the medicine,” Stotland said. “These laws seem to be most often invoked in the refusal of contraceptives, including emergency contraceptives whose efficacy is time-limited.

“The AMA has supported a requirement that pharmacists in these instances inform the prescribing physician—that's good, but it doesn't get the patients their medication,” she said. “We need the AMA to determine the real-life impact of these laws.”

The resolution was supported by physicians from the American College of Obstetricians and Gynecologists and other organizations, which emphasized that a failure to fill a prescription is a failure to treat the patient.

SSRIs During Pregnancy Addressed

The AMA also adopted a report summarizing the state of knowledge on the use of serotonin reuptake inhibitors (SSRIs) during pregnancy and recommending further research into the treatment of depression during pregnancy (see Original article: page 1).

APA President Carolyn Robinowitz, M.D., addressed the issue during reference committee hearings.

“Treatment of depression in pregnancy with SSRIs, like any treatment, requires a thorough communication between the physician and the patient on the risks and benefits of treatment as well as the risks of not treating,” she said. “Recognizing that any medication can have dangerous side effects, you always have to aim for the most informed consent possible.

“Research suggests the risk of treating depression in pregnancy with SSRIs is small, but that depression itself is a risk to mother and baby,” she said.

Robinowitz especially emphasized the fact that many insurers will not reimburse patients for nonpharmacologic treatments. “It is a distressing fact that third-party payers will pay for medication but are less willing to reimburse the patient for nonpharmacologic treatment, which may be of great benefit,” she said.

Execution Involvement Policy Upheld

Finally the AMA approved a resolution reaffirming the organization's prohibition on physician involvement in execution of defendants convicted of capital offenses. The resolution was brought by the Section Council on Psychiatry.

However, another resolution calling for a national moratorium on executions generally, brought to the house by the New Jersey state delegation, failed as it has in previous meetings.

Forensic psychiatrist Howard Zonana, M.D., reiterated APA's support for a moratorium, which is also supported by the American Academy of Psychiatry and the Law and the American Bar Association.

“The politics of the death penalty has shifted dramatically in favor of death,” he said. “Legislators have consistently strengthened the number of crimes [punishable by death] and cut back the funding for defense of capital defendants. This has resulted in a process whereby you get death not for having committed the worst crime, but for having been assigned the worst lawyer.”

He noted that defendants who receive a court-appointed lawyer have been found to have a 28 percent greater probability of getting convicted and a 44 percent greater chance of getting the death penalty than defendants who have the means to hire their own lawyer.

But Art Klawitter, M.D., a physician from Texas, spoke for the prevailing opinion of the house.

“This is a moral issue where there is diverse opinion,” he said. “The house itself is divided. It's a membership issue for that member who is looking for the last straw to tell him to stop paying dues.

“In Texas, legislators listen to us very closely when we talk about tort reform, regulatory relief, payment reform, scope of practice, and public health,” he said. “The last thing they want to hear from us is about reforming the criminal-justice system.” ▪