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Although human trafficking is recognized as a public health issue, research on the health effects of human trafficking and best intervention practices is limited. We describe 2 citywide collaborative victim services models, the THRIVE (Trafficking, Healthcare, Resources, and Interdisciplinary Victim Services and Education) Clinic at the University of Miami and Jackson Health System in Miami, Florida, and the Greater Houston Area Pathways for Advocacy-based, Trauma-Informed Healthcare (PATH) Collaborative at Baylor College of Medicine, CommonSpirit Health, and San Jose Clinic in Houston, Texas, funded in part by the Office for Victims of Crime, which focus on trauma-informed health care delivery for victims of human trafficking. From June 2015 through September 2021, the THRIVE Clinic served 214 patients with an average age of 28.7 years at the time of their first visit. From October 2017 through September 2021, the PATH Collaborative received 560 suspected trafficking referrals, 400 of which screened positive for labor or sex trafficking. These models serve as a framework for replication of interdisciplinary practices to provide health care for this unique population and preliminary information about the strategies put in place to assist victims during their recovery. Key lessons include the importance of a citywide needs assessment, patient navigators, interdisciplinary care, and building community partnerships to ensure safe housing, transportation, identification, health insurance, vocation services, input from survivors, peer-to-peer mentorship, and medical–legal services. Further research is needed to understand the detrimental health effects of trafficking and the health care needs of victims. In addition, a need exists to develop optimal models of care for recovery and reintegration for this patient population and to address public health, legal, and medical policies to ensure access to and sustainability of comprehensive, trauma-informed, interdisciplinary victim services.

It is estimated that 40 million people worldwide have experienced human trafficking (UN, International Labour Organization & Walk-Free Foundation, 2019), with 313,000 trafficked persons in the state of Texas alone (Busch-Armendariz et al., 2016). These staggering numbers are indicative of human trafficking as a growing public health concern. To date researchers have neither studied nor proposed a specific psychotherapeutic modality in the treatment of trafficked persons. Given the unique concerns of this populations, including mistrust of authority, emotional coercion, and abuse by traffickers, often co-occurring substance use concerns, and difficulty with standard treatment adherence, we propose a therapeutic strategy that might assist providers in addressing a broad range of concerns, particularly assisting trafficked persons in the effort to leave their situation. This strategy is motivational interviewing (MI; Miller et al., 2009) and has shown substantial efficacy to enhance motivation to change as applied within in a broad range of healthcare settings. We briefly review the broad tenants of MI and illustrate its application within two hypothetical cases of trafficking. Future research that examines the potential benefits of MI within trafficking populations is warranted.

Foreign-born individuals immigrating to or residing in the United States are especially vulnerable to exploitation by traffickers. Being trafficked elevates the risk for a variety of physical and mental health problems; thus, victims will often come into contact with health professionals. Because there is a dearth of literature concerning the treatment of human trafficking victims, and especially foreign-born victims, we set out to describe the practical applications of a model that we use for the mental health treatment of victimization in this population. As has been suggested by leaders in the anti-human trafficking community, we employed a culturally sensitive version of Bronfrenbrenner’s Ecological Systems Model to provide recommendations and educational resources for treatment at the individual, interpersonal, community, and societal levels. Our recommendations should serve to inform and improve the provision of care for foreign-born victims of human trafficking.

Trustworthiness is the cornerstone professional virtue in the practice of medicine. The authors' goals for this Invited Commentary were to provide an account of the professional virtue of trustworthiness and its historical origins as well as to suggest how trustworthiness in a professional curriculum can be taught and assessed. They identified 2 components of trustworthiness that originate in the work of John Gregory (1724-1773) and Thomas Percival (1740-1804), who invented the ethical concept of medicine as a profession. The first is intellectual trust, the commitment to scientific and clinical excellence. The second is moral trust, the primary commitment of physicians and health care organizations to promote and protect the interest of patients while keeping individual and group interests secondary. Teaching should focus first on the mastery and understanding of the conceptual vocabulary of intellectual and moral trust through a range of formats, including modeling by faculty on how they respect and treat patients and learners. Assessment should be behaviorally based and articulated in increasing, observable, and integrated levels of mastery through training. Medical educators and academic leaders also share the responsibility to inculcate and sustain an organizational culture of professionalism that is respectful, critically self-appraising, accountable, and committed to its learners and to the promotion of physician well-being. These proposals can be used by medical educators and academic leaders to assist learners to become and remain trustworthy physicians.

Limited opportunities exist for university premedical students to gain exposure to the realities of clinical practice through physician shadowing or through a formal curriculum. Medical Professionalism and Observership utilizes didactics, reflective writing, small- and large- group discussions, and clinical observerships to enhance the process of professional identity formation during a critical developmental window of late- adolescence. The pilot semester included a sample of 135 students, all in their sophomore, junior, or senior years of study at Rice University. Students were selected through an application process and paired with physicians at Houston Methodist Hospital based on specialty preference and availability. Students were required to participate in biweekly lectures and discussions and to submit a weekly reflection on topics discussed in the course and their shadowing experiences. Student evaluations were administered to survey changes in students’ knowledge and perceptions of the curriculum. Selected reflections were read for evidence of professional identity formation. Lectures increased students’ exposure to core competencies within the medical profession and influenced their desire to become physicians. Reflective writings demonstrated integration of these core competencies into the professional identity of students. Structured reflection and didactics, when coupled with physician shadowing, appear to promote integration of the values, beliefs, and attitudes of medical professionalism. Future studies should seek to demonstrate how such a curriculum affects professional identity formation through established measures, and to assess whether such a curriculum may influence students’ preparedness for medical training and practice as they progress along their careers.

In response to the COVID-19 pandemic, the Association of American Medical Colleges has called for a temporary suspension of clinical teaching activities for medical students. Planning for the continued involvement of learners in patient care during this pandemic should include teaching learners professional formation. The authors provide an ethical framework to guide such teaching, based on the ethical principle of beneficence and the professional virtues of courage and self-sacrifice from professional ethics in medicine. The authors show that these concepts support the conclusion that learners are ethically obligated to accept reasonable, but not unreasonable, risk. Based on this ethical framework, the authors provide an account of the process of teaching professional formation that medical educators and academic leaders should implement. Medical educators and academic leaders should embrace the opportunity that the COVID-19 pandemic presents for teaching professional formation. Learners should acquire the conceptual vocabulary of professional formation. Learners should recognize that risk of infection from patients is unavoidable. Learners should become aware of established ethical standards for professional responsibility during epidemics from the history of medicine. Learners should master understandable fear. Medical educators and academic leaders should ensure that didactic teaching of professional formation continues when it becomes justified to end learners' participation in the processes of patient care; topics should include the professionally responsible management of scarce medical resources. The COVID-19 pandemic will not be the last major infectious disease that puts learners at risk. Professional ethics in medicine provides powerful conceptual tools that can be used as an ethical framework to guide medical educators to teach learners, who will bear leadership responsibilities in responses to future pandemics, professional formation.

In their article, “How Payment for Research Participation Can Be Coercive,” authors Millum and Garnett argue that there are two distinct forms of coercion: a more “traditional” view, which they cal...

This article discusses the complexities and ethical challenges for determining medical capacity as it pertains to ability for self-care and independence in discharge planning. Determining capacity for acute and long-term decision making is complicated for geriatric patients whose cognition may fluctuate during the course of an inpatient hospital stay. Balancing respect for a patient's autonomy and the practitioner's value of beneficence is an ethical concern. The patient presented in this article is a 72-year-old woman whose cognitive functioning was measured as very impaired for several weeks but then drastically improved over 1 month but she would not accept the safer option of discharge to a residential care facility opposed to her own home. Clinicians struggled to identify when baseline functioning had been truly identified and when maximum capacity could be accurately assessed. Decisions about long-term care need to be based on executive capacity as well as task-specific decision-making capacity. [ Psychiatr Ann . 2016;46(2):127–131.]

Self-neglect among older adults results in increased morbidity and mortality rates. Depression is strongly linked to self-neglect and when untreated, severely complicates management of health and functional outcomes. The study aims to identify factors correlated with depression to inform approaches to service recruitment and retention that improve long-term outcomes. The sample included urban community-dwelling older adults (n = 96) 65 years of age and older with Adult Protective Services-substantiated self-neglect. All participants completed a range of validated cognitive, functional, and self-report demographic and clinical measures around health and mental health functioning. A secondary data analysis using multivariable logistic regression revealed that a positive screen for alcohol abuse, low self-rated health, and higher self-reported pain were associated with significantly higher odds of self-reported depression. Further research is needed to understand the temporality between these correlates and depression and to inform prevention and intervention practices for self-neglecting older adults.

This article highlights the complexity of ethical challenges that can arise in treatment planning for patients with serious medical and mental health conditions. The patient presented here is terminally ill with an acute exacerbation needing an urgent procedure; she is pregnant with a previable fetus and her mental status is unstable. In this case, the role of the psychiatrist extends beyond merely assessing her decision-making capacity; the psychiatrist should also help to identify the patient’s values, which, along with the ethical concepts of the fetus as a patient, beneficence, and respect for autonomy, can then guide treatment planning by the care team and the patient’s surrogate decision-maker. The psychiatrist can also help to identify countertransference to allow for the least biased decision-making. [ Psychiatr Ann . 2015;45(2):89–93.]

Many medical schools now offer students a distinctive clinical and learning opportunity, the student-run clinic (SRC), in which generalist physicians often play the major role. Although SRCs have become popular, they pose as-yet unexplored ethical challenges for the learning experiences of students. In SRCs students not only take on a significant administrative role especially in coordinating care, but also provide direct patient care for a clinically challenging, biopsychosocially vulnerable, medically indigent population of patients. SRCs provide an exemplar of the ethical challenges of care for such patients.The ethical framework proposed in this article emphasizes that these valued learning opportunities for students should occur in the context of professional formation, with explicit attention to developing the professional virtues, with faculty as role models for these virtues.The valued learning opportunities for students in SRCs should occur in the context of professional formation, with explicit attention to developing the professional virtues of integrity, compassion, self-effacement, self-sacrifice, and courage, which are required for the appropriate care of the vulnerable populations served by SRCs.

There are few studies of the manner in which media portray the mental state of mass killers. There are also no formally tested frameworks or models for understanding how such portrayals contribute to the stigma of mental illness. In this article we analyzed the initial depictions of a high-profile mass killer applying discourse analytic methods to representations of the Tucson shooter, Jared Loughner, in the New York Times. We identified fourteen items that focused on Loughner and his actions that were published over the 1st week after the shooting prior to any authoritative assessment of his mental state. This study sought to deconstruct this portrayal of the killer as “mad”, and to show how the four cultural mechanisms of language in use, culture, social practices, and institutions contributed to that construction. Those cultural mechanisms underpinned links observed in the items between Loughner’s behavior, his putative mental illness, and the mass murders. This seamless interplay between the cultural mechanisms as related intertextually enabled the differing representations of Loughner as mad, dangerous, and fearsome. We argue that such a portrayal is a significant contributor to stigmatizing understandings of mental illness and people’s fear of mental disorders.

The best interests of a pregnant psychotic patient can be served by determining her decision making capacity and using surrogate decision making if needed.

The literature has documented the opportunities to improve mental health care by developing programs to work with clergy for identifying and supporting individuals with mental illness. A successful program would integrate and coordinate mental health service rehabilitative and treatment programs with religious community resources. The authors systematically reviewed the efficaciousness of providing mental health outreach to religious settings. Although many programs were found that had exhibited an impressive degree of integration and coordination between mental health and religious groups, only one had incorporated outcome measures. The lack of use of validated outcome measures severely limits our understanding of the utility of mental health outreach programs to religious settings. This is an important public health area for the development of research.

Objective Deliberate foreign body ingestion (DFBI) is often impulsively driven, repetitive and refractory to intervention and frequently necessitates multiple medical interventions. As such, the frustrations among health care providers are great, and the financial toll on health care is significant. Nevertheless, the literature on DFBI is sparse, and suggestions for treatment planning and management are limited. The authors sought to investigate and uncover efficacious treatments and strategies for preventing reoccurrence in DFBI. We build on earlier work by offering both broad and diagnosis-specific management strategies. Method A literature review was performed addressing the presentation, management and prevention of reoccurrences of DFBI. Four cases of DFBI are presented illustrating those psychiatric diagnoses (psychosis, malingering, obsessive–compulsive disorder and borderline personality disorder) most frequently encountered in hospital practice. Both broad and specific treatment approaches are presented. Results Patients engaging in DFBI are best managed through a multidisciplinary approach, following acute medical management. Successful strategies for the prevention of reoccurrences of DFBI are inconclusive. Conclusion Understanding the function of this behavior is critical in developing treatment for patients who engage in these dangerous, potentially life-threatening, self-injurious behaviors. An amalgam of medical, pharmacological and cognitive–behavioral interventions is recommended, as is additional research.

As the American Medical Association emphasized, guns are the means of a number of injuries and deaths. According to 2007 data, firearm suicides account for approximately 50% of all suicides in the United States alone, and firearm homicides account for approximately 69% of all homicides. Firearms are present in around 35% of all U.S. households. The presence of a firearm in the home is a risk factor for suicide and homicide, although this is not explained by elevated levels of psychopathology in those households. Moreover, media portrayals of mental illness are frequently characterized by crime and violence, and occasions of mass murder by firearms, although uncommon, can attract widespread and negative media coverage. Preventing any one such occasion should contribute greatly to limiting stigmatizing depictions. One perspective is that many family practitioners and psychiatrists focus almost exclusively on trying to reduce the number of suicides by recognizing and treating mental disorders, while not doing enough to restrict access to lethal means. Evidence suggests that restricting access to lethal methods, at least by legislative initiatives, decreases suicides by those methods.

The authors review existing assessment tools related to evaluating residents’ teaching skills and teaching effectiveness. PubMed and PsycInfo databases were searched using combinations of keywords including “residents,” “residents as teachers,” “teaching skills,” and “assessments” or “rating scales.” Eleven evaluation tools that utilized self-reports, learner evaluations, or observed structured teaching evaluations were found. These varied in length from one to 58 items, most of which were both valid and reliable. Additional evaluation tools were found that utilized direct audio- or videotaped recordings of teaching. This toolbox should facilitate program directors and others in assessing residents’ teaching skills and should promote rigorously conducted research on residents as teachers.

This special edition provides a compendium of information about global and human rights challenges facing psychiatry and the steps required to meet those challenges. It focuses on the ethical issue...

This Open Forum commentary reviews the ethical considerations relevant to the question of prosecuting assaultive psychiatric patients, with particular attention to the significance that should be attached to the arguments generated by those considerations. A comprehensive literature search was conducted incorporating the terms "assaultive patients," "ethics," "psychiatric inpatients," and "law." The literature of professional medical ethics was applied to identify relevant domains of ethical argument. Five domains were identified: fiduciary obligations of physicians to assaultive and other patients; obligations to staff members; professional virtues of compassion, self-sacrifice, and self-effacement; retributive justice; and the patient's right to confidentiality. The content of each domain is explained, and guidance is provided on how to assess the relative strengths of ethical argument within each domain. All five domains must be explicitly addressed in order to make ethically disciplined judgments about whether to seek prosecution. A distinctive feature of this ethical analysis is the central importance of the professional virtues.

Medical school and residency training programs are intended to provide positive educational and mentorship experiences and to inculcate a culture of professionalism and collegiality. Academic psychiatrists often contribute greatly to these positive efforts, given the emphasis in their work on psychotherapeutic and interpersonal skills and their attentiveness to conflict prevention and resolution. It is very reasonable to expect, therefore, that occasions of verbal abuse or bullying of trainees would be very low in prevalence in psychiatric settings. Is this a realistic expectation or merely a statement of what we would like to believe about our profession? In their cross-sectional survey study of 71% of all trainees in psychiatry registered with the College of Physicians and Surgeons in Pakistan, Ahmer and colleagues (1) demonstrated that disrespectful interactions may be the rule rather than the exception in psychiatric residents’ educational experience. Fully 80% of the psychiatry trainees in this study (60 respondents, response rate 71%) had been the victim of at least one bullying behavior in the preceding 12 months. The most commonly encountered behaviors were persistent attempts to belittle and undermine the work of the trainee or to humiliate the trainee in front of colleagues. The greatest source of mistreatment was from consultants (74%), as well as peers (36%), managers (22%), and nurses (13%). Interestingly, patients (16%) also were identified as engaging in verbal abuse and bullying behaviors toward psychiatric trainees. To what degree are the findings of Ahmer et al. (1) likely similar or dissimilar to other educational settings in psychiatry and beyond? One of our goals for this editorial is to try to answer this question. We also intend to place this information on the verbal abuses or bullying of psychiatry trainees into context with relevant findings from medical students, residents in other specialties, and nurses. Finally, we will make recommendations for future research in this area. As Ahmer et al. (1) noted, the possible consequences of any attempts to belittle or undermine and humiliate residents are serious and warrant attention. Verbal aggression, abuse, or bullying incorporates a wide range of behaviors including threats, intimidation, humiliation, excessive criticism, covert innuendo, exclusion or denial of access to opportunity, undue additions to work requirements, and shifting of responsibilities without appropriate notice (2, 3). Such occasions, especially when repeated, could take the form of psychological harassment, creating distress and dissatisfaction in the training environment. Indeed, mistreatment in professional settings unfortunately comes in many forms. These are widely varying behaviors that are not easily defined or validated as abuse or bullying; therefore, in capturing relevant information on mistreatment in psychiatry training, a key challenge was to find all the relevant articles pertaining to the verbal abuse or bullying of psychiatry residents. We used a combination of search teams including “abuse,” “bullying,” “harassment,” “intimidation,” “discrimination,” “horizontal violence,” “aggression,” and “interpersonal conflict” and “psychiatry residents.” We searched databases including PubMed, Embase, and PsycINFO. The reference lists of relevant articles were also searched for additional references. Furthermore, because articles published in Academic Psychiatry prior to 2001 were not readily located through PubMed, we searched the indexes of Academic Psychiatry for additional information. We Received April 7, 2009; accepted April 8, 2009. Dr. Coverdale is affiliated with the Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine in Houston; Dr. Balon is affiliated with Wayne State University, Detroit; Dr. Roberts is affiliated with the Department of Psychiatry and Behavioral Medicine at the Medical College of Wisconsin in Milwaukee. Address correspondence to John H. Coverdale, M.D., Baylor College of Medicine, Department of Psychiatry and Behavioral Sciences, One Baylor Plaza BCM 350, Houston, TX 77030; jhc@bcm.tmc.edu (e-mail). Copyright © 2009 Academic Psychiatry

Objectives: We surveyed the prevalence of various types of threats or assaults by patients against psychiatrists and determined the impact of the most distressing event. Method: An anonymous questionnaire was mailed to all 308 vocationally registered psychiatrists practicing in New Zealand. Results: A response rate of 63.9% ( n = 197) was obtained. In the preceding 12 months, as many as 46% ( n = 89) of respondents had been verbally threatened and 39% ( n = 76) had been physically intimidated by patients. In addition 16% ( n = 32) had been assaulted without requiring medical attention, 14% ( n = 27) had been harassed through formal complaint mechanisms, 10% ( n = 20) had been sexually harassed, and 5% ( n = 9) had been stalked. As indicated by responses on the Impact of Event Scale, only one-third of the psychiatrists had any symptoms related to the most distressing event and only two had symptoms that might be associated with clinically significant levels of distress. Conclusions: The prevalence of these events suggest a need for the development and evaluation of preventive interventions.

Because of the clinical significance of patient suicide for trainees and current limited information on this essential educational subject, the authors sought to determine what topics involving the care of suicidal patients were taught to residents in psychiatry training programs.Chief residents of psychiatry training programs across the United States (response rate 59%) anonymously completed questions on what and how the care of suicidal patients was taught. Topics that required more attention and barriers to teaching were also identified.A vast majority of the national programs (91%) offered formal teaching on suicide care; grand rounds (85%) and case conferences (80%) were also popular methods for teaching. Even the topics most commonly taught, such as risk factors, recognizing early warning signs, and standards of clinical care, were judged to warrant more attention by many residents. Commonly identified barriers to teaching included the lack of audio or video teaching materials and relevant texts. Only 19% of chief residents reported that they felt prepared for the possibility of having to manage the aftermath of a patient suicide.The chief residents identified a need for programs to focus even more attention on teaching of the care of suicidal patients in training programs.

No life remains untouched by suicide. In the United States, there are more than 31,000 suicides each year, with a national rate of 11 deaths per 100,000 people. This is roughly double the death rate by homicide and by alcohol-induced deaths. In comparison with patterns related to physical illnesses, it is more than twice the rate of deaths each year by AIDS and brain cancer, the same death rate as ovarian cancer and pancreatic cancer, and half the death rate by breast cancer, pneumonia, and Alzheimer’s disease (1). The personal and intergenerational impact of suicide is immense, and the lost years of contribution by those who take their lives represent a tremendous, perhaps immeasurable loss to our society. As specialists in mental illnesses which are most highly associated with death by suicide, psychiatrists are called upon to provide distinct expertise and effective clinical services in relation to this highly significant public health issue. A corollary, then, is that academic psychiatrists must help prepare psychiatrists-intraining for the responsibility of caring for people at risk for suicide and learning how best to respond as a professional to the tragedy that suicide always is. In this issue, Fang et al. (2) reviewed the literature concerning residents’ experiences and psychiatry training program responses when a patient dies by suicide. One impetus for their review was a recognition that psychiatry residents are likely to experience the suicide of at least one patient during training, with estimates ranging from around 32% to 61% (3–8). Fang et al. noted that there are few studies informing residency training programs about how to prepare residents for the possibility of a patient’s suicide or about how to support residents afterward. One of their goals was to encourage the profession to develop guidelines to support residents in their work with suicidal patients and for managing the aftermath. Because of the importance we attributed to this topic

It has been suggested that physicians are particularly vulnerable to being stalked. Our goal was to examine the prevalence of physicians who have been stalked and the associated consequences for the victims. We conducted multiple searches of PubMed and PsycINFO for articles in English from 1950 to 2013, using the terms stalker, stalking, aggression, assaults, patient, physician, resident, registrar, intern, and trainee. Reference lists of relevant articles were also searched. We developed and used a five-point evaluation tool for critical appraisal of the articles. We found 12 prevalence studies on the stalking of physicians, of which 8 were national surveys and 4 were focused exclusively on stalking. The studies varied in their methodological quality with common limitations including the lack of a national sample, the lack of construct validity of the survey tool and of the provision of a formal definition of stalking, and low response rates. Prevalence rates ranged from 2 to 25 percent, although one study found a prevalence rate of 68.5 percent. Information on the physical and psychological consequences of having been stalked was also limited. Although a substantial minority of physicians reported having been stalked, there remains a dearth of high-quality studies on the topic.

This article offers a practical account of intertextuality and its impacts on media portrayals of violent crimes by persons living with a mental illness. We analysed interrelationships across reports, on the same page, of violent crimes by two different individuals diagnosed with a mental illness. The materials were drawn from a practically complete, prospectively collected national sample of print materials (600 items). Reports utilised complementary understandings of mental illness as either pushing a competent person out of control or as associated with routine incompetence and violent criminal action. Three themes relevant to forensic psychiatrists were identified: patient rights versus public safety; community members active or passive; and mental illness and agency. Photographs, texts and page layouts, rendered each depiction more threatening, enhancing perceived threats of violence and crime associated with mental illness. An appreciation of such interrelationships would appear to be necessary for more effective engagement with lay understandings of mental illnesses and media reports of violent crimes.

There have been no studies describing the occurrence of untreated medical condition(s) in elders with depression who self-neglect. This study compares the prevalence of depression as indicated by an abnormal score (or = 5) on the Geriatric Depression Scale-Short Form (GDS-SF) between self-neglecters and matched non self-neglecting community-dwelling elders. It also describes the relationship between untreated medical condition(s) associated with self-neglect and abnormal scores on the GDS-SF.The two samples consisted of 50 self-neglect cases validated by Adult Protective Services and 50 matched non-self-neglecters recruited from a hospital geriatric unit. The cases and controls were matched on age, gender, ethnicity and socio-economic status when possible. All were assessed in their home. Each participant received a comprehensive geriatric assessment, which included the Geriatric Depression Scale-Short Form, the Mini-Mental State Exam, the Self-Rated Health and Mortality question, and the Physical Performance Test. A laboratory blood analysis was also conducted. Untreated medical condition(s) was determined during the assessment by a geriatric nurse practitioner.There was a statistically significant difference in the distribution of abnormal GDS-SF scores between the self-neglect (n = 25, 51%) versus the control group (n = 14, 28%; X2 = 5.49, df = 1, p = .019). Self-neglecters with scores indicative of depression were also significantly more likely (56% vs. 21%) to have untreated medical condition(s) compared to self-neglecters scoring normal on the GDS-SF (OR = 4.84, 95% CI = 1.37-17.09).Clinicians should anticipate untreated medical condition(s) in elderly patients with depressive symptomatology who self-neglect.

Objective We present a preventive ethics approach for including women of childbearing potential in clinical trials. Study design We explain the concept of preventive ethics and identify its implications for study design, the informed consent process, and study management. Results We identify and address ethically significant questions for investigators and institutional review boards to address, to responsibly enroll women of childbearing potential in clinical trials. These questions concern preventive ethics for study design, for the informed consent process, and for study management. Distinctive components of this preventive ethics approach include the distinction between directive and nondirective counseling, the recognition of the concept of moral risk for women as research subjects, and the distinction between professional and individual conscience. We identify ethical considerations for physicians considering referral of their patients to clinical trials. Conclusion A comprehensive, preventive ethics approach to the ethical challenges in clinical trials related to the prevention and occurrence of pregnancy is essential for responsibly enrolling women of childbearing potential.

Background It has been hypothesized that a degree of coercion is a necessary component in using outpatient commitment to attain therapeutic outcome for those people subject to mental health law. However, what degree of coercion is required and how it is sustained is poorly understood. There is speculation that patients' recognition of beneficial as well as unwanted aspects of outpatient commitment (ambivalence) maybe an indicator that the necessary level of coercion has been achieved to facilitate a therapeutic outcome. Aim The aim of this study was to determine the level of coercion perceived by those under outpatient commitment in New Zealand. Emphasis was given to consideration of the presence of ambivalence and the role of interactive processes, including procedural justice, in influencing patients' perceptions of coercion. Method A cross-sectional comparative study was undertaken to compare the perceptions of coercion of patients on outpatient commitment (n = 69) to a matched sample of voluntary outpatients (n = 69), using the Perceived Coercion Scale. The influence of a range of variables, including patients' knowledge of and beliefs concerning outpatient commitment, were considered. Results Although the level of coercion for involuntary outpatients was relatively low, it was significantly higher than that experienced by voluntary outpatients. Yet involuntary outpatients were more likely to espouse benefits of outpatient commitment. Although there was an inverse correlation between perceptions of procedural justice and perceived coercion, procedural justice did not feature in the linear regression analysis. Discussion In the New Zealand context, involuntary outpatients hold contrasting views to outpatient commitment. We suggest that this ambivalence is an indicator that the degree of coercion is suffice to achieve therapeutic outcome. Furthermore, this study suggests the impact of procedural justice on patients' perceptions of coercion may be more crucial during admission to hospital than in the context of on-going community care.

Objective To develop ethically justified clinical strategies for promoting geriatric assent with a focus on the application of professional virtues. Method The concept of geriatric assent was extended to all geriatric patients incapacitated by cognitive impairments, including dementias, and practical clinical steps for promoting geriatric assent were developed. Results A four step-process for promoting geriatric assent is proposed by balancing the principles of beneficence and respect for autonomy within the context of the psychiatrist's virtues. These four steps include identifying the patient's long-standing values and preferences; assessing plans of care in terms of biopsychosocial safety and independence along with the patient's values and preferences; protecting remaining autonomy; and cultivating the professional virtues of steadiness, self-effacement, and self-sacrifice when making decisions that risk the patient's future health and safety. Conclusions In promoting geriatric assent, psychiatrists are obligated to support and directively counsel the patient's surrogate to adopt care plans that promote the patient's values and preferences to the extent possible. These clinical strategies for promoting geriatric assent should serve to enhance the patient's remaining sense of integrity and dignity. These strategies should also protect remaining health status and therefore protect remaining autonomy. Copyright © 2006 John Wiley & Sons, Ltd.

Objective We present and defend ethically justified guidelines for pharmacologic research that involves pregnant women. Study design We explain the ethical concept of the fetus as a patient and identify its ethical implications for the design and conduct of pharmacologic research that is intended to benefit pregnant women. Results This concept justifies criteria for the initiation of early-phase clinical investigation, the initiation of controlled trials, the use of placebo control subjects, the stopping of randomized controlled trials, the determination of when an experimental intervention should be regarded as standard of care, and research that involves adolescents. The informed consent process should be shaped by the pregnant patient's obligation to take in to account her beneficence-based obligations to a fetal patient. Selection criteria should not be based on abortion preference. And, physicians are justified ethically in referring pregnant women to trials. Conclusion The concept of the fetus as a patient plays an essential role in the ethically justified design and conduct of pharmacologic research in pregnant women.

Objective: Having found no discussions of self-depictions offered by psychiatric patients in the mass media we sought such items in a prospective national sample of print media and analysed how those speakers portrayed themselves. Method: As part of a larger study of media depictions of mental illnesses in print media all items with any mental health or illness aspect that appeared in a New Zealand publication over a four-week period were collected. The resulting collection of 600 items ranged from news briefs to full-page newspaper articles. From that set we selected and analysed items in which a person identified as having been a psychiatric patient or as having a mental disorder was either quoted by the reporter who had interviewed them, or personally described their experiences. Employing both propositional analyses and discourse analysis we explored how the speakers were positioned and identified patterns or themes in their construction of living with a mental illness. Results: Only five articles (0.8%) met our criteria for a person with a mental disorder being reported directly. In those items the journalists had positioned the speakers as credible, expert sources who, in representing their lives and experiences, drew on five clusters of resources, that we titled: Ordinariness/Living Well; Vulnerability; Stigma; Crisis; and Disorder/ Treatment. Ordinariness/Living Well foregrounded the role of personal strengths in living well and in overcoming adversity, particularly that associated with being stigmatized. We identified that theme as central to the ways in which these speakers depicted themselves as recognizably human and understandable. Conclusion: The findings are preliminary but these depictions are different from those reported by most researchers. Unlike those depictions, these speakers provided accessible and recognizably human self-portrayals. That finding intensifies our concern that most researchers appear to be unaware that these consumer voices are largely absent from mass media depictions of mental illnesses.

Dr. Roberts is the Editor-in-Chief of Academic Psychiatry. Drs. Coverdale and Louie are the Associate Editors for Academic Psychiatry. Ms. Edenharder is the Assistant to the Editors. Copyright 2004 Academic Psychiatry. A thoughtful review of a manuscript is a gift. It is a gift of expertise, of time, and of careful consideration. It is a gift for authors, editors, and the field. Performing a thoughtful peer evaluation of a manuscript is an acquired skill, however, and one that may not be formally taught in many academic departments or postgraduate training programs. The aim of this short piece is to provide some “down-to-earth” guidance for early career faculty, prospective authors, and peer reviewers on how to write a manuscript review. This represents a fundamental skill in academics, and this paper is the first in a series that will appear in our journal providing “down-to-earth” guidance related to academic skills for our readers.

We implemented team learning, an instructional method that fosters small-group learning, in an evidence-based medicine (EBM) course. Our goal was to align instructional methods with EBM practices.Team learning provides an alternative to lectures in large-group settings. It involves out-of-class preparation followed by in-class readiness assurance tests and group application activities. We used the method to teach a 7-week course in EBM for 2nd-year students. We evaluated the course using student performance, external observation, and student focus groups.Students performed well on all written assignments, indicating attainment of learning objectives. Observation data revealed a high level of student engagement in the classroom. Focus group data indicated that desired learning behaviors tended to occur but that many students devalued the method.Team learning served as a useful framework, enabling a large enrollment course to have small-group experiences without large numbers of faculty. The method fostered individual accountability and promoted teamwork--behaviors consistent with effective EBM practice. Students' lack of enthusiasm for the method may stem from their comfort with didactic lectures.

This article proposes an ethically justified forensic approach to extended suicide associated with major depression. Extended suicide is the phenomenon of murder of a family member(s) by a suicidal person when murder is viewed as a way to protect the family member(s) from a life of suffering. The effects of depression on autonomy (decision-making capacity) and particularly on evaluative understanding are reviewed. Autonomy-based implications of major depression are inconsistent with legal and clinical assessments based on a threshold concept that defendants either absolutely appreciated the moral wrongfulness of their actions or did not appreciate such consequences. Forensic responses should alternatively be based on clinical assessments that delineate the level of impairment of autonomy over a continuum.