Longitudinality Matters: Qualitative Perspectives on a Longitudinal Clinical Experience in a Psychiatry Residency Training Program.

OBJECTIVE: Longitudinal models of clinical care and education can positively impact the patient and provider experience in terms of health outcomes, satisfaction, and motivation. While residency programs have seen an increase in primary care longitudinal clinical experiences (LCEs), defined as outpatient clinics in which patients are seen by residents over the course of their entire training, less is known about such opportunities in psychiatry residency programs. This qualitative study explores the impact of a longitudinal training model on psychiatric resident skill development, relationships in the clinical learning environment, and professional identity formation. METHODS: The authors conducted 24 semi-structured interviews of residents, graduates, and faculty in three well-established LCE clinics in a single, multi-site, academic psychiatry residency program. Transcripts were analyzed using inductive thematic analysis techniques. RESULTS: Themes were categorized into benefits and challenges. For benefits, themes included longitudinal relationships, improved feedback, near-peer teaching, early outpatient exposure, graduated independence, skill development, patient population expertise, and solidification of professional identity. For challenges, themes included system logistics, offsite panel management, and intermittent presence of junior trainees. CONCLUSION: Results suggest that overall, residents and faculty find the LCE a positive learning opportunity that has contributed to their professional development. LCEs do appear to have distinct challenges, largely logistical in nature, which can interfere with the favorability of residents' experiences. Developing strategies up front to minimize these logistical challenges will support the success of a longitudinal program.

Psychotropic medication use in treatment-seeking youth with eating disorders.

OBJECTIVE: Psychotropic medication use in youth with eating disorders (EDs) is poorly understood despite high co-occurrence of psychiatric disorders. This study examined characteristics associated with medication use in treatment-seeking youth with EDs. METHOD: Youth up to age 18 reported on medication use when presenting to an academic medical center outpatient ED service in the United States. Data presented were collected between 1998-2015. RESULTS: The sample (N = 604) was predominantly female (90.6%) with a mean age of 15.3 years (SD = 2.3). Approximately one-third (30%, n = 173) were taking psychotropic medications (40%, n = 70, were taking multiple medications). Antidepressant use was most common (26%, n = 152), followed by atypical antipsychotics (8%, n = 43). Adjusting for co-occurring psychiatric disorders, non-Hispanic Whites who had received prior treatment (psychotherapy, hospitalization) were significantly more likely to be using medication. Longer illness duration and prior treatment were associated with greater antidepressant use. For atypical antipsychotics, prior hospitalization was associated with greater use. CONCLUSIONS: Findings confirm moderate psychotropic medication use among young patients with EDs despite a lack of clarity regarding optimally effective pharmacologic interventions in this population. Pharmacological trials examining the efficacy of medications for young patients with EDs are warranted to inform future prescribing practice.

Case Report: Buprenorphine Induction Using Transdermal Buprenorphine in a Veteran With Opioid Use Disorder and Psychosis, Managing Precipitated Withdrawal.

Buprenorphine induction can lead to precipitated opioid withdrawal, even when using novel techniques such as transdermal buprenorphine. Involuntary limb movements are a distressing symptom of precipitated withdrawal that can be difficult to treat. We report a case of a military veteran transitioning from methadone to buprenorphine for the treatment of opioid use disorder (OUD) using small doses of transdermal buprenorphine. Herein, we review the literature associated with opioid withdrawal-related restlessness. Despite the known risk of concurrent benzodiazepine and buprenorphine administration, including decreased respiratory rate and death, we present a clinical presentation in which this medication combination may be necessary while under medical supervision. We suggest a stepwise algorithm for pharmacotherapy in patients experiencing involuntary limb movements associated with precipitated withdrawal. To safeguard the success of medication-assisted treatment (MAT) for opioid addiction, clinicians should be aware of potential clinical challenges when managing precipitated opioid withdrawal in patients with complex psychiatric comorbidities.

Rituals and preoccupations associated with bulimia nervosa in adolescents: Does motivation to change matter?

This study evaluated the effects of two treatments for adolescent bulimia nervosa (BN), family-based treatment (FBT-BN), and cognitive behavioral therapy (CBT-A), on both attitudinal and behavioural outcomes at end-of-treatment. These associations were examined specifically relative to motivation for change in obsessive-compulsive (OC) features of eating disorder (ED) symptoms. Adolescents (N = 110) were randomly assigned to FBT-BN or CBT-A and completed assessments of eating pathology and OC-ED behaviour. Across both treatments, greater motivation for change in OC-ED behaviour was associated with improved attitudinal features of ED at end-of-treatment. Motivation for change did not demonstrate a direct or interaction effect on BN behavioural outcomes. Results suggest that adolescents with BN who are more motivated to change OC-ED behaviours at the start of treatment, FBT-BN or CBT-A, are more likely to demonstrate improvements in cognitions, but not behaviours associated with EDs, at treatment conclusion.

A test of the DSM-5 severity specifier for bulimia nervosa in adolescents: Can we anticipate clinical treatment outcomes?

OBJECTIVE: This study tested clinical utility of the DSM-5 severity specifier for bulimia nervosa (BN) in predicting treatment response among adolescents (N = 110) within a randomized clinical trial of two psychosocial treatments. METHOD: Analyses grouped individuals meeting criteria for BN diagnosis by baseline severity, per DSM-5. Associations among baseline severity classification and BN behavior (i.e., binge eating and compensatory behavior) and eating disorder examination (EDE) Global scores at end-of-treatment (EOT), 6- and 12-month follow-up were examined. RESULTS: Associations between severity categories with BN symptoms were not significant at EOT, or follow-up. Test for linear trend in BN behavior was significant at EOT, F = 5.23, p = 0.02, without demonstrating a linear pattern. Relation between severity categories with EDE Global scores was significant at 6-month follow-up, F = 3.76, p = 0.01. Tests for linear trend in EDE Global scores were significant at EOT, F = 5.40, p = 0.02, and at 6 months, F = 10.73, p = 0.002, with the expected linear pattern. DISCUSSION: Findings suggest the DSM-5 BN severity specifier holds questionable utility in anticipating outpatient treatment response in adolescents with BN. The specifier may have improved ability to predict attitudinal rather than behavioral treatment outcomes.

Residents' and Fellows' Knowledge and Attitudes About Eating Disorders at an Academic Medical Center.

OBJECTIVE: This study examined physician residents' and fellows' knowledge of eating disorders and their attitudes toward patients with eating disorders. METHODS: Eighty physicians across disciplines completed a survey. The response rate for this survey across disciplines was 64.5 %. RESULTS: Participants demonstrated limited knowledge of eating disorders and reported minimal comfort levels treating patients with eating disorders. Psychiatry discipline (p = 0.002), eating disorder experience (p = 0.010), and having ≥4 eating disorder-continuing medical education credits (p = 0.037) predicted better knowledge of anorexia nervosa but not bulimia nervosa. Psychiatry residents (p = 0.041), and those who had treated at least one eating disorder patient (p = 0.006), reported significantly greater comfort treating patients with eating disorders. CONCLUSION: These results suggest that residents and fellows from this sample may benefit from training to increase awareness and confidence necessary to treat patients with eating disorders. Sufficient knowledge and comfort are critical since physicians are often the first health care provider to have contact with patients who have undiagnosed eating disorders.

Does Sex Matter in the Clinical Presentation of Eating Disorders in Youth?

PURPOSE: Eating disorders (EDs) impact both males and females, but little is known about sex differences in ED psychopathology and overall clinical presentation. This study compared demographic and clinical characteristics of child and adolescent males and females who presented for ED treatment. METHODS: Participants included 619 youth (59 males and 560 females) ages 6-18 years who presented for treatment between 1999 and 2011. RESULTS: Males presented for ED treatment at a significantly younger age (p < .001), earlier age of onset (p = .004), and were more likely to be nonwhite (p = .023). Females showed more severe ED pathology across the Eating Disorder Examination subscales (weight concern: p < .001; eating concern: p < .001; restraint: p = .001; and shape concern: p = .019) and global score (p < .001). Males were more likely to present with an ED other than anorexia nervosa or bulimia nervosa (p = .002). Females presented with significantly higher rates of mood disorders (p = .027) and had a lower average percent of expected body weight (p = .020). Males and females did not differ in duration of illness, prior hospitalization or treatment, binging and purging episodes, anxiety disorders, behavioral disorders, or self-esteem. All analyses were controlled for age. CONCLUSIONS: Results indicate that further exploration into why the sexes present differently may be warranted. Developing ED psychopathology assessments that better capture nuances particular to males and reevaluating criteria to better categorize male ED diagnoses may allow for more targeted treatment.