Psychiatrists' Cognitive and Affective Biases and the Practice of Psychopharmacology: Why Do Psychiatrists Differ From One Another in How They View and Prescribe Certain Medication Classes?

ABSTRACT: Cognitive and affective biases impact clinical decision-making in general medicine. This article explores how such biases might specifically affect psychiatrists' attitudes and prescribing patterns regarding two medication classes (stimulants and benzodiazepines) and addresses related issues. To supplement personal observations, selective PubMed narrative literature searches were conducted using relevant title/abstract terms, followed by snowballing for additional pertinent titles. Acknowledging that there are many more types of biases, we describe and use clinical vignettes to illustrate 17 cognitive and affective biases that might influence clinicians' psychopharmacological practices. Factors possibly underlying these biases include temperamental differences and both preprofessional and professional socialization. Mitigating strategies can reduce the potentially detrimental impacts that biases may impose on clinical care. How extensively these biases appear, how they differ among psychiatrists and across classes of medication, and how they might be most effectively addressed to minimize harms deserve further systematic study.

Thirty-Minute Psychiatric Management Visits in Academic Medical Centers: Framing and Exploring Distinct Clinical-Educational Social Processes.

ABSTRACT: To address high clinical demand and manage workflow, some university-based practice settings are tending to replace traditional hour-long outpatient appointments with 30-minute psychiatric management visits, which must comply with multiple regulatory requirements for documentation and billing. This care model can significantly shape the culture of psychiatric treatment and education. Based on the limited published literature on this topic and pooled experiences of faculty, residents, and administrators, this article offers observations and raises questions concerning 1) clinical, educational and administrative benefits, limitations, and challenges for conducting 30-minute psychiatric visits in training contexts; 2) how administrative impositions affecting resident and faculty time and attention impact clinical encounters; 3) how various teaching settings manage regulatory requirements differently; and 4) considerations for education needs and opportunities, research gaps, and policy implications. Quality of care and education could be improved by judicious overhaul of administrative requirements to minimize burdens offering little clinical or educational value.

An Integrative Framework of Appraisal and Adaptation in Serious Medical Illness.

Multiple randomized clinical trials have demonstrated that palliative care improves the quality of life of individuals with serious medical illness. Research also suggests that in patients with advanced cancer, palliative care's focus on symptom management, coping with illness, goals of care, and treatment decisions may be associated with improved patient quality of life in part by increasing patients' use of active (vs. passive) and approach-oriented (vs. avoidant) coping strategies. However, without a framework outlining the process that individuals with serious medical illness and their loved ones undergo, it is challenging to discern exactly where, how, and why palliative care may affect the serious medical illness experience. To address this gap, we propose a clinically applicable framework, derived from existing theory and research in the social and behavioral sciences. This framework, called the Integrative Framework of Appraisal and Adaptation in Serious Medical Illness, describes how patients and their loved ones cognitively and emotionally process the various events that may occur as they navigate serious medical illness and the end of life. The framework also describes how individuals and their loved ones use that event processing to determine next steps, while considering the impact of their surrounding external environment, their individual social roles, and their connections on this decision making. The framework presented in this article is intended to improve our ability to understand and care for individuals with serious medical illness and their loved ones, while stimulating further discussion and research to test and refine these ideas.

Hospice use for the patient with advanced Alzheimer's disease: the role of the geriatric psychiatrist.

Advanced Alzheimer's disease (AD) can place an immense burden on caregivers as they struggle to provide end-of-life (EOL) care for the patient. Palliative care, as delivered by hospice, provides a viable solution. Hospice maintains the patient's quality of life (QOL) and helps the family during the grieving process. However, many providers are not familiar with hospice and its care for advanced AD patients. Geriatric psychiatrists can be central in implementing hospice, and they can remain an important part of the care once it is in place. A principal clinical challenge is establishing the six-month prognosis for such patients, which is a prerequisite for initiating hospice admission.

Hospice use for the patient with advanced Alzheimer's disease: the role of the geriatric psychiatrist.

Advanced Alzheimer's disease (AD) can place an immense burden on caregivers as they struggle to provide end-of-life (EOL) care for the patient. Palliative care, as delivered by hospice, provides a viable solution. Hospice maintains the patient's quality of life (QOL) and helps the family during the grieving process. However, many providers are not familiar with hospice and its care for advanced AD patients. Geriatric psychiatrists can be central in implementing hospice, and they can remain an important part of the care once it is in place. A principal clinical challenge is establishing the six-month prognosis for such patients, which is a prerequisite for initiating hospice admission.

Health service utilization by Alzheimer's disease patients: a 2-year follow-up of primary versus subspecialty care.

All dementia patients and their caregivers who had received a university-based comprehensive evaluation and a diagnosis of Alzheimer's disease during 1997 (N = 80) were identified. Of the original cohort, 48.8% (n = 39) were able to be contacted approximately 2 years after their initial assessment, and the caregivers were the informants for this follow-up. Two subgroups were defined: 22 patients were being seen only by their primary care physicians (MED), while 17 patients were also being treated by a geriatric psychiatry faculty member (GERO). There were statistically significant differences between the 2 groups (MED versus GERO, respectively) at follow-up in terms of (1) institutionalization (30.0% versus 4.6%, P < .05), (2) CDR (2.3 versus 1.5, P < .005), and (3) prescription of donepezil at follow-up (45.5% versus 76.5%, P = .05). These differences are being assessed in a larger scale prospective study.