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 AMA Gears Up for Report on
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
An issue that attracted enormous press coverage was the AMA's attention to
the possibly detrimental psychosocial effects of video and Internet games on
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.
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.
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
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.
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
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." ▪