Changes in psychiatry residents' attitudes towards individuals with substance use disorders over the course of residency training.

BACKGROUND AND OBJECTIVES: Psychiatry residents provide care for individuals diagnosed with co-occurring mental illness and substance use disorders (SUDs). Small studies have shown that clinicians in general possess negative attitudes towards these dually diagnosed individuals. This is a serious concern, as clinicians' stigmatizing attitudes towards individuals with mental illnesses may have a particularly potent adverse impact on treatment. The goal of this study was to examine the attitudes of psychiatry residents towards individuals with diagnoses of schizophrenia, multiple SUDs, co-occurring schizophrenia and SUDs, and major depressive disorder. METHODS: A questionnaire was sent to psychiatry residents (N = 159) around the country. It was comprised of two sections: (i) demographic information, which included information about level of training; and (ii) the 11-item Medical Condition Regard Scale (MCRS) for individuals with the four different diagnoses. RESULTS: Psychiatry residents had more stigmatizing attitudes towards individuals with diagnoses of SUDs with and without schizophrenia than towards those individuals with diagnoses of schizophrenia or major depressive disorder alone. Senior residents possessed more negative attitudes towards individuals with SUDs than junior residents. DISCUSSION AND CONCLUSIONS: The attitudes of psychiatry residents' towards individuals with SUDs with and without schizophrenia were negative and were worse among senior residents. There were many potential reasons for these findings, including repeat negative experiences in providing care for these individuals. SCIENTIFIC SIGNIFICANCE: The negative attitudes of psychiatry residents towards individuals with SUDs are worrisome. Future work is needed to better understand these attitudes and to develop interventions to improve them. (Am J Addict 2017;26:75-79).

Use of Electronic Resources for Psychiatry Clerkship Learning: A Medical Student Survey.

OBJECTIVE: The primary aim of this study is to examine medical students' use patterns, preferences, and perceptions of electronic educational resources available for psychiatry clerkship learning. METHODS: Eligible participants included medical students who had completed the psychiatry clerkship during a 24-month period. An internet-based questionnaire was used to collect information regarding the outcomes described above. RESULTS: A total of 68 medical students responded to the survey. Most respondents reported high utilization of electronic resources on an array of devices for psychiatry clerkship learning and indicated a preference for electronic over print resources. The most commonly endorsed barriers to the use of electronic resources were that the source contained irrelevant and non-specific content, access was associated with a financial cost, and faculty guidance on recommended resources was insufficient. Respondents indicated a wish for more psychiatry-specific electronic learning resources. CONCLUSION: The authors' results suggest that a demand exists for high-quality electronic and portable learning tools that are relevant to medical student education in psychiatry. Psychiatry educators are usefully positioned to be involved in the development of such resources.

Assessing Decision Making Capacity for Do Not Resuscitate Requests in Depressed Patients: How to Apply the "Communication" and "Appreciation" Criteria.

The Patient Self Determination Act (PSDA) of 1991 brought much needed attention to the importance of advance care planning and surrogate decision-making. The purpose of this law is to ensure that a patient's preferences for medical care are recognized and promoted, even if the patient loses decision-making capacity (DMC). In general, patients are presumed to have DMC. A patient's DMC may come under question when distortions in thinking and understanding due to illness, delirium, depression or other psychiatric symptoms are identified or suspected. Physicians and other healthcare professionals working in hospital settings where medical illness is frequently comorbid with depression, adjustment disorders, demoralization and suicidal ideation, can expect to encounter ethical tension when medically sick patients who are also depressed or suicidal request do not resuscitate orders.

Type and duration of subsyndromal symptoms in youth with bipolar I disorder prior to their first manic episode.

OBJECTIVES: The aim of the present study was to systematically evaluate the prodrome to mania in youth. METHODS: New-onset/worsening symptoms/signs of ≥ moderate severity preceding first mania were systematically assessed in 52 youth (16.2 ± 2.8 years) with a research diagnosis of bipolar I disorder (BD-I). Youth and/or caregivers underwent semi-structured interviews, using the Bipolar Prodrome Symptom Scale-Retrospective. RESULTS: The mania prodrome was reported to start gradually in most youth (88.5%), with either slow (59.6%) or rapid (28.8%) deterioration, while a rapid-onset-and-deterioration prodrome was rare (11.5%). The manic prodrome, conservatively defined as requiring ≥ 3 symptoms, lasted 10.3 ± 14.4 months [95% confidence interval (CI): 6.3-14.4], being present for ≥ 4 months in 65.4% of subjects. Among prodromal symptoms reported in ≥ 50% of youth, three were subthreshold manic in nature (irritability: 61.5%, racing thoughts: 59.6%, increased energy/activity: 50.0%), two were nonspecific (decreased school/work functioning: 65.4%, mood swings/lability: 57.7%), and one each was depressive (depressed mood: 53.8%) or subthreshold manic/depressive (inattention: 51.9%). A decreasing number of youth had ≥ 1 (84.6%), ≥ 2 (48.1%), or ≥ 3 (26.9%) 'specific' subthreshold mania symptoms (i.e., elation, grandiosity, decreased need for sleep, racing thoughts, or hypersexuality), lasting 9.5 ± 14.9 months (95% CI: 5.0-14.0), 3.5 ± 3.5 months (95% CI: 2.0-4.9), and 3.0 ± 3.2 months (95% CI: 1.0-5.0) for ≥ 1, ≥ 2, or ≥ 3 specific symptoms, respectively. CONCLUSIONS: In youth with BD-I, a relatively long, predominantly slow-onset mania prodrome appears to be common, including subthreshold manic and depressive psychopathology symptoms. This suggests that early clinical identification and intervention may be feasible in bipolar disorder. Identifying biological markers associated with clinical symptoms of impending mania may help to increase chances for early detection and prevention before full mania.

Religious conversion in a psychotic individual.

The authors describe the case of a man who appeared to have psychotic symptoms, including self-injurious behavior, but who understood his own experience as a religious conversion. The symptoms, clinical course, and treatment response are described with reference to the works of Kurt Schneider and William James. Empirical studies of the attitudes of psychiatrists, psychiatric patients, and clergypersons about the relationship between religious belief and psychiatric illness are described, and various theoretical models used to understand this relationship are articulated.

Improvement in Residents' Attitudes Toward Individuals with Substance Use Disorders Following an Online Training Module on Stigma.

BACKGROUND: Resident physicians have been shown to possess negative attitudes toward individuals with substance use disorders (SUDs), even if the residents believe they have adequate knowledge and skills to care for these patients. Residents' negative attitudes may have an adverse impact on patient engagement, treatment, and outcomes. QUESTIONS/PURPOSES: The goal of this study was to examine the impact of an online training module on residents' attitudes toward people with SUDs. We hypothesized that residents who received the educational intervention would show improved attitudes toward people with alcohol and opioid use disorders. METHODS: A web-based questionnaire, including demographic information and the Medical Condition Regard Scale (MCRS) about individuals with alcohol and opioid use disorders, was sent to internal medicine and psychiatry residents before and 6 months after they took an online training module on stigma toward individuals with SUDs. RESULTS: A total of 46 residents completed the initial questionnaire and 29 completed the follow-up questionnaire 6 months later. Attitudes toward individuals with SUDs, as reflected by an increase in MCRS scores, were improved 6 months after the online training module. CONCLUSION: Residents' attitudes toward individuals with SUDs improved after taking an online training module. This is encouraging, as studies have shown that attitudes toward individuals with SUDs tend to decline during residency training and negatively affect patient care. Larger studies are needed to determine if such online modules can improve attitudes of other groups of clinicians, result in sustained change over time, and improve patient outcomes.

Attitudes Toward Individuals With Mental Illness and Substance Use Disorders Among Resident Physicians.

OBJECTIVE: Resident physicians frequently provide care for individuals diagnosed with mental illness and substance use disorders (SUDs). Clinicians-including psychiatrists and addiction professionals-have been shown to possess negative attitudes toward these individuals, which is concerning since negative attitudes may have an adverse impact on patient engagement, treatment, and outcomes. However, little is known about resident physicians' attitudes toward individuals with mental illness and SUDs. The objective of this study was to examine the attitudes of emergency medicine, internal medicine, and obstetrics-gynecology residents toward individuals with diagnoses of schizophrenia, multiple SUDs, co-occurring schizophrenia and SUDs, and major depressive disorder. METHODS: A web-based questionnaire, including demographic information, level of training, and the 11-item Medical Condition Regard Scale (MCRS) for individuals with 4 different diagnoses, which assesses the degree to which clinicians find individuals with a given medical condition to be enjoyable, treatable, and worthy of medical resources, was sent to residents across the United States from May 2016 to April 2017. RESULTS: A total of 411 resident physicians completed the questionnaire. Respondents had more negative attitudes toward individuals with diagnoses of SUDs with and without schizophrenia than toward those individuals with diagnoses of schizophrenia or major depressive disorder alone. Senior residents possessed more negative attitudes toward individuals with SUDs than did junior residents. Emergency medicine residents had more negative attitudes than the other resident physician groups. CONCLUSIONS: The attitudes of resident physicians toward individuals with SUDs with and without schizophrenia were negative and were worse among emergency medicine residents and senior residents. Additional research and programmatic work are needed to understand the reasons for these negative attitudes and to develop interventions during residency training to improve them.

Differentiation in the preonset phases of schizophrenia and mood disorders: evidence in support of a bipolar mania prodrome.

OBJECTIVE: The presence and specificity of a bipolar prodrome remains questioned. We aimed to characterize the prodrome prior to a first psychotic and nonpsychotic mania and to examine the phenotypic proximity to the schizophrenia prodrome. METHODS: Using a semi-structured interview, the Bipolar Prodrome Symptom Scale-Retrospective, information regarding the mania prodrome was collected from youth with a research diagnosis of bipolar I disorder and onset before 19 years of age, and/or their caregivers. Only newly emerging, at least moderately severe, symptoms were analyzed. Prodromal characteristics were compared between patients with and without subsequent psychotic mania and with published bipolar and schizophrenia prodrome data. RESULTS: In 52 youth (age at first mania: 13.4 +/- 3.3 years), the prodrome onset was predominantly "insidious" (>1 year, 51.9%) or "subacute" (1-12 months, 44.2%), while "acute" presentations (<1 month, 3.8%) were rare. The prodrome duration was similar in patients with (1.7 +/- 1.8 years, n = 34) and without (1.9 +/- 1.5 years, n = 18) subsequent psychotic mania (P = .70). Attenuated positive symptoms emerging late in the prodrome and increased energy/goal-directed activity were significantly more common in patients with later psychotic mania. Mania and schizophrenia prodrome characteristics overlapped considerably. However, subsyndromal unusual ideas were significantly more likely part of the schizophrenia prodrome, while obsessions/compulsions, suicidality, difficulty thinking/communicating clearly, depressed mood, decreased concentration/memory, tiredness/lack of energy, mood lability, and physical agitation were more likely part of the mania prodrome. CONCLUSIONS: A lengthy and symptomatic prodrome makes clinical high-risk research a feasible goal for bipolar disorder. The phenotypic overlap with the schizophrenia prodrome necessitates the concurrent study of both illness prodromes.

Recognizing and monitoring adverse events of second-generation antipsychotics in children and adolescents.

Although second-generation antipsychotics (SGAs) are used increasingly in children and adolescents, data on the effectiveness and safety in pediatric populations are still sparse. Much of the safety information is derived from studies conducted in adults. This derivation is problematic because children and adolescents are exposed to SGAs during a phase of unparalleled physical and psychologic development that can affect pharmacokinetic and pharmacodynamic drug actions, efficacy, and side-effect patterns. This article presents an overview of SGA-related side effects in children and adolescents and strategies to monitor health outcomes effectively in youngsters receiving SGAs.

Electroconvulsive therapy for the treatment of refractory mania.

We present the case of a patient with treatment-refractory mania. The patient had been tried on numerous medications, to which she either did not respond well or on which she developed severe side effects, However, the patient improved rapidly when treated with unilateral electropercussive therapy (ECT) following a court order. We outline the legal barriers that have been raised against the use of ECT in patients with mania, who often refuse treatment, and the irony that ECT can be safer than medications for some patients. ECT is underutilized in mania but deserves more frequent consideration. (Journal of Psychiatric Practice. 2011;17:61-66).