Clinical review: evidence-based diagnosis and treatment of ADHD in children.

Attention Deficit/Hyperactivity Disorder (ADHD) is the most commonly diagnosed psychiatric disorder in children. Diagnosis is clinical. The role of imaging, rating scales and computerized screening tests in patient evaluation is examined. Management involves the use of medication as well as patient-specific psychosocial intervention. Psychostimulants are first line agents and have been shown to be highly efficacious for treating ADHD. Mode of action and pertinent clinical issues regarding each stimulant and non-stimulant medication uses are discussed.

Evaluating competence in psychotherapy.

BACKGROUND: The Residency Review Committee (RRC) for Psychiatry has recently charged psychiatry training programs with developing methods to demonstrate competence of trainees in five areas of psychotherapy. Each program must decide what specific skills are essential for competence in each of the five listed psychotherapies. This requires determining whether those skills that are necessary are also sufficient for effective psychotherapy and whether additional specific skills are required for each one. METHOD: Two lists of general skills for psychotherapy are compared, one from the perspective of specific "schools" of psychotherapy and one from a more eclectic "integrative" approach. The issue of measuring competence is addressed by placing ratings of "competent" midway on a continuum from "novice" to "expert." Thirteen methods for measuring competence from the Accreditation Council for Graduate medical Education (ACGME) "tool-box" are described and reviewed with respect to applicability to psychotherapy. Examples of toolbox implementation are described based on a functioning psychotherapy evaluation program at the University of Missouri. RESULTS AND CONCLUSIONS: The authors found both theoretical as well as practical problems in measuring competence in psychotherapy. We propose that global rather than highly specific assessment methods may be more practical in these early stages of development, and we offer specific suggestions for assessment components that can currently be implemented.

Two-year follow-up status of emergency department patients with chest pain: Was it panic disorder?

OBJECTIVES: We previously reported that 25% (108/441) of consecutive patients presenting to the emergency department (ED) of the Montreal Heart Institute with a chief complaint of chest pain suffered from panic disorder (PD). The purpose of the present study was to re-examine these patients (with and without PD) 2 years after their initial ED visit to determine their psychiatric and psychosocial status. METHODS: An interviewer, who was kept blind to patients' initial medical and psychiatric diagnoses, attempted to contact all patients who participated in the initial study by phone. Patients who completed the phone interview were sent a battery of psychological questionnaires by mail. RESULTS: A total of 301 (70%) patients completed the phone interview, and 228 (52%) patients completed the self-report questionnaires. Participants and non-participants did not differ with respect to age, gender, initial self-report scores, or initial cardiac or psychiatric diagnoses. At follow-up, significantly (p < 0.05) more PD+ than non-PD (PD-) patients reported: 1) chest pains in the last month (57% vs. 31%); 2) one or more ED consultations in the past year for chest pain (40% vs. 14%); 3) one or more hospitalizations in the past year (31% vs. 11%); and 4) perceiving their general health as "poor" (22% vs. 9%). PD+ patients displayed a significant (p < 0.05) worsening of their panic symptoms, agoraphobic avoidance, depression, and trait anxiety, and reported significantly (p < 0.05) greater suicidal ideation compared to PD- patients (32% vs. 9%). Of all PD+ patients, only 22% (18/82) reported receiving some form of mental health treatment for their symptoms. CONCLUSIONS: Unrecognized and untreated PD has a chronic and disabling course. Greater efforts should be made to screen for PD in patients complaining of chest pain in EDs.