May 2014

Vol. 26. No. 2


Ten years and counting

It has been my pleasure to serve as editor-in-chief of Annals of Clinical Psychiatry since 2004, after taking over from founding editor, Charles L. Rich, MD. He provided an independent and rigorous review of each submission, and eschewed any hint of author bias. In an editorial accompanying the first issue in March 1989, he wrote that the intent of Annals was to bridge the gap between researchers and practitioners and to “seek material that is as scientifically meritorious as it is clinically meaningful.” This has been the organizing principle of Annals and the American Academy of Clinical Psychiatrists (AACP): to bring clinicians and researchers together to enhance one another’s work. I believe we have succeeded…



Preadmission Screening and Resident Review (PASRR) regulation and its implications for patients, hospitals, nursing homes, and the taxpayers

Subramoniam Madhusoodanan, MD | Sylvester A. Nwedo, MD | Ronald Brenner, MD | Omar Mirza, DO

BACKGROUND: This study assessed the impact of the revision of the Preadmission Screening and Resident Review (PASRR) regulation changes in September 2011, which increased the turnaround time for PASRR evaluations from 3 to 5 days to 2 to 3 weeks.

METHODS: From January 2013 to March 2013, we tracked all patients’ charts in a 25-bed inpatient geriatric psychiatric unit in New York where PASRR evaluations were requested. The turnaround time and related issues were analyzed.

RESULTS: There were 27 patients who had PASRR requests during the study period; 9 patients were not included in the study because of incomplete data. The average turnaround time for the 18 patients was 14.89 days and the additional hospital bed cost per patient was $11,911.11.

CONCLUSIONS: Although PASRR has played a positive role in identifying persons with serious mental illness and the need to provide the services they need, the recent revision of the PASRR regulation in 2011 has significantly increased the hospital bed costs.


An empirical data comparison of regulatory agency and malpractice legal problems for psychiatrists

James Reich, MD | Alan Schatzberg, MD

BACKGROUND: Our objective is to compare legal difficulties that psychiatrists encounter in regulatory agency and malpractice (insurance) settings.

METHODS: Data sources included a literature search of malpractice and medical board discipline from 1990 to 2009 (rates and types of discipline); publicly available insurance data (malpractice frequency and type); and data from the National Practitioner Data Bank (NPDB) (required reports of malpractice settlements and hospital discipline).

RESULTS: Medical board discipline findings indicate that psychiatrists are at increased risk of disciplinary action compared with other specialties. NPDB data indicated relatively infrequent problems for psychiatrists. In malpractice, psychiatry accounted for a small percentage of overall claims and settlements. Overall, more years in practice and a lack of board certification increased the risk of legal difficulties.

CONCLUSIONS: There are shared and separate risk factors in the malpractice and regulatory agency areas, but there is evidence that these 2 legal areas are distinct from each other.


Empathy and childhood maltreatment: A mixed-methods investigation

Simon C. Locher, B.SocSci. (Hons) | Lisa Barenblatt, B.SocSci. (Hons) | Melike M. Fourie, PhD | Dan J. Stein, FRCPC, PhD | Pumla Gobodo-Madikizela, PhD

BACKGROUND: Impaired empathy is regarded as a psychological consequence of childhood maltreatment, yet few studies have explored this relationship empirically. We investigated whether empathy differed in healthy and maltreated individuals by examining their emotional responses to people in distress.

METHODS: Forty-nine individuals (age 20 to 60) viewed short film clips from the South African Truth and Reconciliation Commission testimonies depicting dialogues between victims and perpetrators of gross human rights violations. Participants were divided into 3 groups based on their scores on the Childhood Trauma Questionnaire: control (n = 18), moderate maltreatment (n = 21), and severe maltreatment (n = 10). We employed a mixed-methods design to explore empathic responses to film clips both quantitatively and qualitatively.

RESULTS: Quantitative results indicated that self-reported empathy was lower in the moderate maltreatment group compared to the control group, but of similar strengths in the severe maltreatment and control groups. However, qualitative thematic analysis indicated that both maltreatment groups displayed themes of impaired empathy.

CONCLUSIONS: Our results support the notion that childhood maltreatment is associated with impaired empathy, and suggest that such impairment may differ depending on the level of maltreatment: moderate maltreatment was associated with emotional blunting and impaired cognitive empathy, whereas severe maltreatment was associated with emotional over-arousal and diminished cognitive insight.



Anti-N-methyl-d-aspartate receptor encephalitis: A targeted review of clinical presentation, diagnosis, and approaches to psychopharmacologic management

Jennifer L. Kruse, MD* | Jessica K. Jeffrey, MD, MPH, MBA* | Michael C. Davis, MD, PhD | Joanna Dearlove, MD, MPH | Waguih William IsHak, MD, FAPA | John O. Brooks III, PhD, MD

BACKGROUND: Anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis was formally described in 2007 and includes a range of psychiatric and neurologic symptoms. Most patients with anti-NMDAR encephalitis initially present to psychiatrists for diagnosis and treatment. However, there is limited literature summarizing treatment strategies for psychiatric symptoms. In an effort to improve identification and treatment, this review article provides an overview of anti-NMDAR encephalitis, with a focus on psychopharmacologic treatment strategies. Two case reports provide a clinical context for the literature review.

METHODS: The authors conducted a PubMed search.

RESULTS: Prominent psychiatric symptoms of anti-NMDAR encephalitis include psychosis, agitation, insomnia, and catatonia. Neuroleptics may be helpful for managing psychosis and agitation, but may exacerbate movement abnormalities. Diphenhydramine and benzodiazepines are helpful for agitation and insomnia. In addition, the anticholinergic affinity of diphenhydramine can improve dystonia or rigidity attributable to anti-NMDAR encephalitis, while benzodiazepines and electroconvulsive therapy have been used for catatonia associated with this condition.

CONCLUSIONS: Psychiatrists play an important role in the diagnosis and treatment of anti-NMDAR encephalitis. Recognizing the typical clinical progression and closely monitoring for accompanying neurologic symptoms will facilitate diagnosis and timely treatment. Careful selection of psychopharmacological interventions may reduce suffering.