Competencies for Repetitive Transcranial Magnetic Stimulation in Postgraduate Medical Education: Expert Consensus Using a Modified Delphi Process.

BACKGROUND: Repetitive transcranial magnetic stimulation (rTMS) is recommended in Canadian guidelines as a first-line treatment for major depressive disorder. With the shift towards competency-based medical education, it remains unclear how to determine when a resident is considered competent in applying knowledge of rTMS to patient care. Given inconsistencies between postgraduate training programmes with regards to training requirements, defining competencies will improve the standard of care in rTMS delivery. OBJECTIVE: The goal of this study was to develop competencies for rTMS that can be implemented into a competency-based training curriculum in postgraduate training programmes. METHODS: A working group drafted competencies for postgraduate psychiatry trainees. Fourteen rTMS experts from across Canada were invited to participate in the modified Delphi process. RESULTS: Ten experts participated in all three rounds of the modified Delphi process. A total of 20 items reached a consensus. There was improvement in the Cronbach's alpha over the rounds of modified Delphi process (Cronbach's alpha increased from 0.554 to 0.824) suggesting improvement in internal consistency. The intraclass correlation coefficient (ICC) increased from 0.543 to 0.805 suggesting improved interrater agreement. CONCLUSIONS: This modified Delphi process resulted in expert consensus on competencies to be acquired during postgraduate medical education programmes where a learner is training to become competent as a consultant and/or practitioner in rTMS treatment. This is a field that still requires development, and it is expected that as more evidence emerges the competencies will be further refined. These results will help the development of other curricula in interventional psychiatry.

Substance abuse versus dependence and the structure of common mental disorders.

BACKGROUND: In 1999, using data from the National Comorbidity Survey (NCS), Krueger presented a model that gave a novel taxonomic approach to mental disorders and their core psychopathologies. He proposed that the relationships among 10 common mental disorders could be understood in a factor structure composed of higher-order "Internalizing" and "Externalizing" factors, with the Internalizing factor subdivided into an "Anxious-Misery" subfactor and a "Fear" subfactor. However, Krueger did not include all of the mental disorders assessed in the NCS. The objective of the current study was to examine how alcohol abuse and drug abuse compare to alcohol dependence and drug dependence in Krueger's model. METHOD: The sample for this research was the 8098 noninstitutionalized US civilians aged 15 to 54 years who participated in the NCS between 1990 and 1992. The data from the NCS were analyzed using confirmatory factor analyses. RESULTS: Alcohol abuse and drug abuse loaded on both the Anxious-Misery subfactor and the Externalizing factor and were distinct from alcohol dependence and drug dependence. CONCLUSIONS: Individuals with drug abuse and alcohol abuse constitute a different population than individuals with drug dependence and alcohol dependence and have a different pattern of comorbidities. This suggests that underlying etiologies may vary between these 2 groups, leading to different approaches for both research and treatment.

Weight restoration in a patient with anorexia nervosa on dialysis.

OBJECTIVE: We report a case of weight restoration in a patient with anorexia nervosa, end-stage renal disease (ESRD) requiring dialysis, and cardiac insufficiency. METHOD: The technical challenges and ethical issues involved in her clinical management are reviewed. Renal insufficiency is a common complication of more severe anorexia nervosa. RESULTS: Progression to renal failure, when it occurs, is most typically a terminal event. There are currently no published guidelines for monitoring the weight gain of patients undergoing dialysis. CONCLUSION: We present a case of a patient who progressed from renal insufficiency to renal failure while in treatment for anorexia nervosa, and who was ultimately successfully weight restored while on renal dialysis.