Five years from now, the American Board of Psychiatry and Neurology (ABPN)
will implement a new feature in its maintenance-of-certification program.
Psychiatrists will have to evaluate themselves on the quality of the patient
care they provide. The rationale for implementing this feature is that a
number of studies have demonstrated a gap between recommended evidence-based
best practices and the actual care that psychiatrists provide.
To give psychiatrists experience in assessing the quality of the care they
provide to patients with posttraumatic stress disorder (PTSD) before the ABPN
requirement kicks in, APA has developed two Performance in Practice tools.
They were published in the spring FOCUS: The Journal of Lifelong Learning
The first tool is a traditional chart-review approach to assessment. It
allows psychiatrists to evaluate the care that they have given to five
patients with PTSD. Some questions relate to initial assessment and treatment,
others to subsequent care. They can then see how the various aspects of their
patient care match up with evidence-based recommendations and where they might
want to make improvements.
The second tool allows psychiatrists to evaluate the quality of their care
for patients with PTSD in real time. They can complete the self-assessment
form immediately after a patient's first visit and see how their care compares
with the recommendations, and then, if there are disparities, they can adjust
their treatment plan.
Both tools highlight aspects of care that have substantial public-health
implications, such as suicide risk and substance abuse, or for which
disparities between clinical care and recommended guidelines are common.
The evidence-based recommendations included in the two practice tools are
derived from the "APA Practice Guideline for the Treatment of Patients
With Acute Stress Disorder and Posttraumatic Stress Disorder" and"
Clinical Practice Guideline for the Management of Posttraumatic
Stress," a publication of the U.S. departments of Defense and Veterans
One of the recommendations, for example, is the following: "SSRIs are
considered the first-line psychopharmacologic intervention. However, SSRIs are
no longer recommended with the same level of confidence for combat-related
PTSD as for non-combat-related PTSD." Another recommendation states:"
Exposure-based therapies . . . are considered first-line evidence-based
psychotherapeutic interventions. However, exposure therapies are not indicated
and should be used with caution for patients living in dangerous situations
(e.g., domestic violence) or for patients with current suicidal ideation,
substance abuse not in stable remission, comorbid psychosis, or health
problems that preclude exposure to intense physiological arousal."
The PTSD practice tools were designed by Farifteh Duffy, Ph.D., director of
quality-of-care research at the American Psychiatric Institute for Research
and Education (APIRE), in conjunction with APIRE colleagues and a consultant.
The reason they decided to design practice tools for PTSD rather than for
another disorder, Duffy explained to Psychiatric News, is that"
this is an area of significant interest given the high rates of PTSD
among service members and veterans of the Iraq and Afghanistan wars, the
availability of practice guidelines and recent updates through APA's Guideline
Watch for PTSD, as well as APIRE's obtaining the Department of Defense PTSD
Research Program Concept Award in September 2008."
Duffy and her colleagues published their first practice tools—for
depression—last year. "The majority of the psychiatrists who
completed the tools found them to be well designed and of value in improving
practice or verifying that their current care was appropriate," she
said. "Some two-thirds reported that they identified at least one way in
which they could improve their care of patients with depression."
Duffy and her team hope to develop more practice tools "depending on
the availability of updates for practice guidelines, interest in the field,
and funding support," she noted.
The PTSD practice tools, as well as more information about them, are