APA Council Reports

The Council is preparing a comprehensive review of education and training of psychiatrists for new roles in integration with primary care. The initiative includes:

The Council provided support for the Psychiatry Student Interest Group Network (PsychSIGN), a group run by medical students to serve their peers interested in psychiatry. PsychSIGN seeks to promote the establishment of new psychiatry student interest groups (PsychSIG), support and encourage activity in existing groups, and provide resources to pursue a broad range of activities in medical schools, including community service projects around mental health and illness.

To support medical student and residency educators, the Council has asked the Board of Trustees to waive the DSM-5 copyright restrictions for allied, nonprofit education organizations for use in noncommoditized teaching/educational resources specifically for medical student education. The impetus for this request is the online Clinical Simulation Educational Modules for teaching medical students developed by ADMSEP using DSM-5. These modules are designed to be provided free for use by clerkship directors and medical students for general educational purposes. In some cases, the modules may also meet LCME standards ED-2 and ED-8.

CMELL reviewed and provided feedback to the ACGME on the Psychiatry Milestones. Milestones represents a shift from time-based residency requirements to developmental benchmarks for residents within the six domains of clinical competence over the 4 years of their training.

The Council continues to monitor the following GME issues: combined residencies, and “fast tracking” into addiction psychiatry, psychosomatic medicine, and geriatric psychiatry fellowships.

The Council serves as consultant to the CME activities of APA and to the overall CME program. The Council is involved in shaping APA education, in needs assessment for CME activities, and in identifying psychiatrist knowledge gaps. The Council provided input in the development of educational programs that assist members in their pursuit of self-assessment and lifelong learning and fulfillment of requirements for maintenance of certification. For example, Understanding the Evidence: Off Label Use of Atypical Antipsychotic Medication is a multi-part interactive CME program that disseminates evidence-based information on off-label use of atypical antipsychotics. Supported by a grant from the Agency for Healthcare Research and Quality (AHRQ), the goal of the program is to help physicians make informed treatment decisions when using these medications “off label.” This interactive CME program begins with a self-assessment test, and in the months that follow, a series of multimedia clinical modules will be available for CME credit. The self-assessment test is available at www.apaeducation.org.

The APA also provides CME programs for the district branches. In 2013–2014, the APA Department of CME provided credit to district branch members of the Subcommittee on Joint Sponsorship for over 100 meetings; 22 district branches received CME credit from APA. Many of the district branch meetings covered DSM-5 and changes to CPT coding.

The Scientific Program Committee, chaired by Philip Muskin, M.D, focuses on the CME content to be presented each year at the APA Annual Meeting. The committee also plays a vital role in working with APA staff to ensure that the presenters and content of our meeting meet ACCME guidelines, that sessions are worthy of receiving American Medical Association Physician’s Recognition Award Category 1 Credit, and that the overall program content meets the needs of our members by identifying and correcting learning gaps and clinical practice areas that may need special attention through the CME provided at this meeting. This year’s theme was “Changing the Practice and Perception of Psychiatry.”

The Scientific Program Committee for the Institute on Psychiatric Services, chaired by Hunter L McQuistion, M.D., coordinated the 66th Institute on Psychiatric Services. It took place on October 30th-–November 2, 2014, in San Francisco. The meeting theme, “Integrating Science and Care in a New Era of Population Health,” focused on the changes in service delivery and everyday practice, the scientific advancement of our field, and how society shapes our work. This 4-day conference featured more than 100 expert-led education sessions.

The Council conferred the following awards: the APA Vestermark Psychiatry Educator Award, the Irma Bland Award for Excellence in Teaching Psychiatry Residents, the Nancy C.A. Roeske, M.D. Certificate of Recognition for Excellence in Medical Student Education, the Administrative Psychiatry Award, the Jeanne Spurlock Minority Fellowship Achievement Award, and the Resident Recognition Awards.

The Council focuses on psychiatric care of persons who are medically ill and thus stands at the interface of psychiatry with other medical specialties. It recognizes that integration of biopsychosocial care is vital to the well-being of patients and that full membership in the house of medicine is essential to the well-being of our profession. Specific areas identified in the charge are summarized below followed by Council activity.

The APA’s recommendations for the Choosing Wisely Campaign, a national effort promoting clinician-patient conversations about appropriate care, were released on the day of the Council’s meeting, September 20, 2013. Information about this initiative and APA’s development can be found on the APA website: http://www.psychiatry.org/choosingwisely. As a follow-up to this effort, the Council on Quality Care is working with Consumer Reports (in partner with the ABIM Foundation) to develop official consumer-friendly educational materials based on the list content.

The Councils on Research, Quality Care, and Healthcare Systems and Financing initiated a strategic discussion on an APA-supported registry at the Council on Quality Care Meeting on May 7, 2014. The group determined that a Council-charged work group would be formed to formalize and operationalize decisions on how the APA should move forward with an APA-supported registry. Health care reform is increasing the focus on quality measures and patient outcomes, which can be well captured and reported by registries. Advances in information technology, including electronic data capture and infrastructure to link physicians nationwide, have made large-scale efforts more feasible and have led many specialty associations to explore opportunities to develop and support registries. The work group is tasked with considering what an APA registry would focus on that would be unique, meaningful, and relevant to members (for example, informing practice guidelines, quality assessment for payment, research, and tracking treatment outcomes).

Two work groups are developing new APA practice guidelines on 1) psychiatric evaluation and 2) the use of antipsychotics to treat behavioral symptoms of dementia. The guidelines on psychiatric evaluation are being revised to incorporate the APA Assembly’s feedback, and revised guidelines will be submitted to the Assembly for approval in November. For the guidelines on the use of antipsychotics for patients with dementia, a summary of the systematic evidence review is being drafted, and results from an expert opinion survey are being organized. In addition to the new guidelines, a Guideline Watch on 2007 APA’s Practice Guideline for the Treatment of Patients With Alzheimer’s Disease and Other Dementias is being reviewed. This document is a brief review of important research evidence and developments since the 2007 publication of the guideline. It will be published to accompany the 2007 guideline on PsychiatryOnline.org.

To meet standards of the Institute of Medicine and inclusion criteria of the National Guidelines Clearinghouse, guidelines must be informed by a systematic review of evidence. With support from a grant by the National Library of Medicine, APA is developing an evidence database to make systematic reviews more efficient for future APA guidelines development. In addition to performing systematic reviews in-house, APA develops guidelines using systematic reviews available from the Agency for Healthcare Research and Quality (AHRQ). An AHRQ-contracted evidence-based practice center is currently conducting a systematic review on treatment of bipolar disorder, which was a topic nominated by APA. A draft review is expected to be available in late October or early November of 2014. Other reviews that AHRQ is developing or has already published should also be of interest to APA, including PTSD, MDD, binge-eating disorder, and nonpharmacological interventions for the behavioral symptoms of dementia. The Council continues to discuss some of the strategic directions and questions that pertain to APA’s guideline development process, e.g., how to manage potential conflicts of interest of the guideline writing group members, whether to increase capacity within the guideline project, and to consider use of outside and collaborative efforts to address gaps in guidelines.

The Committee’s name was changed from the Committee on Electronic Health Records to the Committee on Mental Health Information Technology, to encompass additional topics of importance to the field, such as technical data standards, health information exchange, and telemedicine. The group convenes monthly by conference call to oversee various activities, including responding to opportunities for public comment on regulations and other documents; initiating discussions with APP and NLM regarding issues of licensing and permission of incorporating DSM-5 terminology with SNOMED; maintaining discussions with MHIT interest groups (including SAMHSA) regarding coordination of HIT for behavioral health; opening a dialog with national EHR vendors about the scope and EHR needs of the behavioral health community by presenting a webinar (along with representatives from AACAP, SAMHSA, ONC, and HL7); working with the AmericanEHR survey, which has captured information on EHR products used by psychiatrists; contributing to a HIT column in Psychiatric News; and representing APA at HL7, which sets technical standards that will have great influence on how medical documentation is captured and transmitted.

The Council discussed issues and priorities facing the Association with regard to performance measure development and implementation and educating members about these increasingly influential topics. APA collaborates with other entities through national initiatives, such as the AMA-supported Physician Consortium for Performance Improvement (PCPI), and considers measure concepts internally through the practice guideline development process. Health reform will require psychiatry to define quality measures, as health care is moving toward pay-for-quality. It is crucial for the APA to be involved in defining quality measures, to avoid crucial measures pertaining to psychiatry being defined by commercial or other nonmedical groups. There are different philosophical approaches to measure development: developing focused measures on specific psychiatric disorders versus measures that are global to psychiatry (e.g., psychiatric evaluation) or to all of health care (e.g., care coordination, medication reconciliation). The group discussed changes within the PCPI mission, which is affecting specialty society responsibilities for previously developed measures. Measures originally stewarded by the PCPI (adult major depressive disorders, child and adolescent major depressive disorders, dementia, and substance use disorders) will now either be owned and managed by the APA (adult major depressive disorders) or shared among specialty societies (e.g., APA and the American Academy of Neurology will share the rights to the Dementia Measure Set). The group noted that measures are having the largest impact on entities such as hospitals, which have a significant portion of services paid by private insurance and federal programs such as Medicare and Medicaid. In addition, Board certification and medical licensure processes are moving toward incorporating quality measurement concepts, which will have a direct impact on the majority of practicing psychiatrists. The Council has agreed to request that APA administration develop and implement a communication strategy for educating APA leadership and membership about the current state of quality measurement and its impact on psychiatry.

Due to the increased focus on quality improvement and quality measurement focusing on integrated care as a result of health care reform, members of the Council will collaborate with other components, such as the Council on Healthcare Systems and Financing, in tracking and steering developments and educating the field.

Several other work groups have been developed under the Council and are newly active or have received approval to continue to convene. The Patient Safety Work Group will focus on transitions of care that occur when patients are discharged from inpatient care, given that increased rates of suicide occur shortly after discharge from hospitals. The Standards and Survey Procedures Work Group continues to address policy and standards development that include activities with national organizations (e.g., the Joint Commission). The newly formed Mental Health and Psychiatric Apps Work Group will participate in activities related to identifying high-quality, high utility software applications that will assist psychiatric clinician practice. The Gender Dysphoria Work Group’s commission has been extended with the plan to develop resource documents focusing on gender dysphoria treatment. With the first meeting occurring at the APA Annual Meeting in May 2014, the Caucus on Psychotherapy convenes psychiatrists interested in any form of psychotherapy and psychosocial treatment.

During the September 2013 gathering, the Council voted to revise the name of the Caucus on Alternative, Complementary, and Integrated Medicine to the Caucus on Complementary and Alternative Medicine. This modification was approved in 2014 and now gives the Caucus consistency with the nomenclature used by the National Institutes of Health’s (NIH) National Center on Complementary and Alternative Medicine.

Given the high level of public interest in complementary and alternative medicine (CAM), the Council discussed the importance of addressing the variability in quality data that currently exists in the literature. The Caucus agreed to work with the Council’s Diagnostic and Treatment Markers Work Group to develop a paper for publication in an academic journal delineating the current state of the evidence on CAM for specific mental health populations, in hopes of clarifying uncertainties about the integration of CAM in psychiatric medicine.

The Steering Committee on HIV Psychiatry is focused on education, training, optimal clinical care, and research, with special interests in HIV-associated neurocognitive disorders, depressive disorders, and their interaction. In addition, the Committee has focused on hepatitis C virus (HCV) co-infection with HIV and comorbid cognitive impairment, as well as the need to address depression prophylaxis and treatment in this setting.

Current funding from the Substance Abuse and Mental Health Administration for the AIDS Education Project will end on September 30th. The APA submitted a proposal in partnership with the Education Development Center, Inc., the American Psychological Association, and the National Association of Social Workers to continue HIV psychiatric training, expand online HIV clinical education, and support the Minority Medical Student Elective in HIV Psychiatry.

Finally, the Assembly returned to the Joint Reference Committee the Position Statement on the Psychiatric Implications of HIV/HCV Co-Infection. Questions regarding format, references, and clinical treatment were returned to the Council and, subsequently, to original the authors. A revised statement will be returned to the Joint Reference Committee in October.

The chairs of the Council on Research, Council on Quality Care, and Council on Healthcare Systems and Financing have appointed a work group to gather information to assist in decision making around the formation of an APA-sponsored patient registry to support the delivery of quality care and clinical research. This project is particularly relevant in light of recent health care reform under the Affordable Care Act, in which payment and accountability are tied to physician participation in registries. Over the remainder of 2014, the work group will continue discussing key factors in the development and implementation of a patient registry, including its scope, purpose, and layout; how to involve key stakeholders; and timeline and logistical development needs. The work group will prepare a final report of their recommendations to the Joint Reference Committee as to what activities the registry should support and how the APA can best help ensure the registry carries these out.

The Committee reported on its recent efforts to enhance communication about disaster response to district braches and state associations, including providing a listing of designated disaster response liaisons for each district branch and state association through the APA’s website.

An update on the status of the ECT and Neuromodulation Committee and the Task Force to Revise the Practice of ECT was presented to the Council. The Task Force chair noted an upsurge in interest on updating guidelines on the use of Transcranial Magnetic Stimulation (TMS), and the Council agreed that a paper on its clinical application be developed by the Council’s Diagnostic Markers and Treatment Work Group.

At the 2014 Annual Meeting, the group identified several areas of priority in which they will develop position papers. These include diagnostic tests for mood disorders; predictors of patient response in depression; and a critical review of the ketamine literature. Also, as noted above, a position paper will be developed on the clinical use of TMS, and a review paper will be developed summarizing the evidence base on the efficacy of CAM interventions for patients with psychiatric disorders.

The Committee reported on recent award decisions for the APA Award for Research.

The Work Group on Research Training reported on the status of the research colloquium.

The Council was updated on the status of the upcoming Health Services Senior Scholar Award lecture to be presented at the October 2014 Institute on Psychiatric Services meeting in Philadelphia.