APA Prepares Members for Change in Certification Requirements

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 in Psychiatry.

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 Affairs.

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 posted at<http://focus.psychiatryonline.org/cgi/content/abstract/7/2/186>.▪