Contributions of common genetic variants to risk of schizophrenia among individuals of African and Latino ancestry.

Schizophrenia is a common, chronic and debilitating neuropsychiatric syndrome affecting tens of millions of individuals worldwide. While rare genetic variants play a role in the etiology of schizophrenia, most of the currently explained liability is within common variation, suggesting that variation predating the human diaspora out of Africa harbors a large fraction of the common variant attributable heritability. However, common variant association studies in schizophrenia have concentrated mainly on cohorts of European descent. We describe genome-wide association studies of 6152 cases and 3918 controls of admixed African ancestry, and of 1234 cases and 3090 controls of Latino ancestry, representing the largest such study in these populations to date. Combining results from the samples with African ancestry with summary statistics from the Psychiatric Genomics Consortium (PGC) study of schizophrenia yielded seven newly genome-wide significant loci, and we identified an additional eight loci by incorporating the results from samples with Latino ancestry. Leveraging population differences in patterns of linkage disequilibrium, we achieve improved fine-mapping resolution at 22 previously reported and 4 newly significant loci. Polygenic risk score profiling revealed improved prediction based on trans-ancestry meta-analysis results for admixed African (Nagelkerke's R2 = 0.032; liability R2 = 0.017; P < 10-52), Latino (Nagelkerke's R2 = 0.089; liability R2 = 0.021; P < 10-58), and European individuals (Nagelkerke's R2 = 0.089; liability R2 = 0.037; P < 10-113), further highlighting the advantages of incorporating data from diverse human populations.

The Psychology of Schizophrenia: Implications for Biological and Psychotherapeutic Treatments.

The focus on recent advances in the neurobiology of schizophrenia has pushed aside the psychological understanding of the person with schizophrenia for several decades. However, a useful functional psychology of schizophrenia (in distinction to a psychological approach to symptoms) remains clinically important for several reasons: it is a core part of the bio-psycho-social formulation; it helps us understand and connect with persons with schizophrenia; and it provides a framework by which to organize our treatment efforts (both psychotherapeutic and particularly biological), which can improve adherence and outcomes. A coherent psychological model (the deficit model) based on object relations theory best explains all the biological, psychological, clinical, and sociocultural factors relevant to the understanding and treatment of persons with schizophrenia. A better understanding of a coherent psychology of persons with schizophrenia and provision of psychotherapies improves both the biological and psychotherapeutic treatment of persons with schizophrenia.

Knowledge and Attitudes About Attention-Deficit/Hyperactivity Disorder and Specific Learning Disorder in an Urban Indian Population.

Attention-deficit/hyperactivity disorder (ADHD) and specific learning disorders (SLDs) are an important cause of scholastic backwardness among children and often go unrecognized. Few studies have examined knowledge and attitudes toward ADHD and SLD among school-aged children. To address this deficit, 120 school-aged children, attending a child guidance clinic in Mumbai, were interviewed using a questionnaire that examined children's knowledge and attitudes about ADHD and SLD. The results were compared both qualitatively and quantitatively with a frequently occurring medical illness, common cold. Approximately 80% to 100% of children were aware of their illness; however, a large variation was noted in the proportion of children (15%-80%) who could describe their symptoms, provide accurate attributions for their illness, and identify treatment modalities. Children with ADHD reported greater control over their illness. The study identified a significant lack of knowledge about ADHD and SLD among school-aged children in India and discusses implications of this finding.

The new milestones: do we need to take a step back to go a mile forward?

The Milestones Project, like all previous systems and changes in graduate psychiatric education, for example, moving from 3 to 4 years of training or adopting six competency domains, has been devised without any supporting data and does not assess meaningful outcomes, such as improved patient outcomes. No evidence is presented that Milestones-based training will produce better psychiatrists. There is a path forward. First, replace unproven expert consensus with scientific and evidence-based approaches. Second, exchange endpoints that are easy to assess but uncorrelated with real world functioning (e.g., multiple-choice examinations) for outcomes that are meaningful and external to the training program (e.g., patient outcomes). Finally, to prevent possible waste, excess burden, or harm, no changes should be mandated until proven in prospective studies.

A roadmap for observership programs in psychiatry for international medical graduates.

OBJECTIVE: International medical graduates (IMGs) constitute a significant proportion of the psychiatric workforce in the United States. Observership programs serve an important role in preparing IMGs for U.S. residency positions; yet there are limited resources with information available on establishing these observerships, and none specific to psychiatry. In this article, authors present a roadmap for observership programs in psychiatry for IMGs. METHOD: This article draws on the experience of the IMG committee of the Group for Advancement of Psychiatry in establishing observership programs. RESULTS: Authors highlight the benefits of observership programs to IMGs, psychiatry departments, and the U.S. medical system as a whole. The different components of an observership program are presented, along with core competencies that need to be acquired. The authors discuss challenges that observership programs may encounter as well as recommendations for overcoming them. CONCLUSION: Observership programs provide a unique opportunity to integrate IMGs into the U.S. medical system. This article provides a framework for establishing such programs in a way that will optimize their benefits and avoid potential pitfalls.

Rapid Antigen Test Sensitivity for Asymptomatic COVID-19 Screening.

Introduction: Operating in-person instruction, residential living, and other activities at institutions of higher education (IHEs) in the context of the pandemic of severe acute respiratory syndrome-coronavirus 2 (SARS-Cov2) have posed a multitude of challenges. Identification of asymptomatic cases at IHEs is crucial, as a large reservoir of virus can potentially develop among students. Unfortunately, despite the advantages, rapid antigen tests (RATs) have variously been shown to perform poorly when used with asymptomatic individuals. Methods: In order to address the appropriateness of RAT use in screening asymptomatic populations like those at IHEs, we conducted a rapid review of published evaluations of RATs available in the United States, where sensitivity and specificity were reported specifically from asymptomatic populations. We extracted sensitivity and specificity for asymptomatic populations reported in each article, along with location and important notes. The data are presented narratively. Results: A total of 11 articles were included for evaluation and presentation, representing tests from four manufacturers. Sensitivity ranged from 35.8% to a high of about 71%, with caveats to the higher number about exposure. Both the low and high sensitivity rates were observed in Abbott BinaxNOW RATs. Due to heterogeneity and publishing differences, a meta-analysis was not feasible, but RAT tests in asymptomatic populations tended to identify roughly half of those identified as infected via reverse transcription-polymerase chain reaction. Specificity ranged from 97.8% to 100%. Conclusion: The results of this rapid review indicate serious issues in misidentifying asymptomatic individuals as COVID-19 negative, when in fact they are infected and carrying the SARS-Cov2 virus.

International Medical Graduates: Promoting Equity and Belonging.

International medical school graduates (IMGs) play a vital role in the health care system of the United States. They constitute roughly one-quarter of the physician workforce, comprising a significant proportion of the primary care providers in high-need rural and urban areas, where they provide equal and, in some instances, better care than U.S. graduates. Nonetheless, they face a series of hurdles in entering U.S. residency programs and throughout their training experiences.IMGs must expend significant resources to obtain Education Commission for Foreign Medical Graduates certification, which includes Steps 1, 2 Clinical Knowledge and 2 Clinical Skills of the United States Medical Licensing Examination. They encounter the uncertainty of matching and, if successful, obtaining a visa to enter the United States. Once here, they need to adapt to the complexities of the health care system and familiarize themselves with the cultural nuances, professional behaviors, and communication skills of another country. They encounter biases and microaggressions and lack support groups and mentors. Those who choose an academic career are less likely to obtain leadership positions.This Perspective provides an overview of these challenges and highlights opportunities for change at local and national levels. Specifically, it identifies strategies that would assist IMGs before entry, at entry, during training, at the transition to practice, and in practice. The current COVID-19 pandemic highlights the shortage of physicians in the United States and illustrates the importance of ensuring that IMGs, who are essential health care workers, feel welcome, valued, and recognized for their contributions.

We Must Graduate Physicians, Not Doctors.

Today, medical schools graduate doctors, not physicians. Thousands of doctors who are U.S. citizens and graduates of U.S. and international medical schools will never become physicians because they do not obtain a residency position. Doctors need at least one year of residency to become a licensed physician. However, 4,099 applicants in 2018 and 4,170 in 2019 failed to get a position through the National Resident Matching Program Main Match; about 1,000 students get positions after the Main Match each year. The personal and societal cost is enormous: each year, approximately 3,000 nonphysician doctors cannot use 12,000 education years and three-quarters of a billion dollars they invested in medical education and cannot mitigate the shortfall of 112,000 physicians expected in 2030.To ameliorate this problem, medical schools could guarantee one year of residency. This is affordable: despite federally funded slots being capped, residency positions have increased for 17 consecutive years (20,602 in 2002 to 32,194 in 2019) because residents are cost-effective additions to the workforce. Alternatively, a 3-year curriculum plus required fourth-year primary care residency is another option. The salary during the residency year could equal other first-year residents', or there could be a token amount for this "internship." Both models decrease the cost of medical education; the second financially unburdens the hospital.Since the Flexner Report (when there was no formal postgraduate training), the end point of medical education has moved from readiness for independent medical practice (physician) to readiness for postgraduate training (doctor). To benefit individuals and society, medical education must take steps to ensure that all graduates are physicians, not just doctors.

Pathways to Independent Primary Care Clinical Practice: How Tall Is the Shortest Giant?

Patients can be treated by a physician, a nurse practitioner (NP), or a physician assistant (PA) despite marked differences in the education and training for these three professions. This natural experiment allows examination of a critical question: What is the minimum education and training required to practice primary care? In other words, how tall is the shortest giant? State licensing requirements, not educational bodies, legislate minimum training. The current minimum is 6 years, which includes 27.5 weeks of supervised clinical experience (SCE), for NPs. In comparison, PAs train for 6 years with 45 weeks of SCE, and physicians for at least 8 years with 110 weeks of SCE. Initial, flawed studies show equivalent patient outcomes among the professions. If rigorous follow-up studies confirm equivalence, the content and length of medical education for primary care physicians should be reconsidered. Unmatched medical school graduates, with 7 years of training and 65 weeks of SCE, more than the required minimum for NPs, deserve to practice independently. So do PAs. If equivalence is not confirmed, the minimum requirements for NPs and/or PAs should be raised, including considering a required residency (currently optional). Alternatively, the scope of practice for the three professions could be defined to reflect differences in training. There is an urgent need to set aside preconceived notions and turf battles, conduct rigorous independent studies, and generate meaningful data on practice patterns and patient outcomes. This should inform optimal training, scope of practice, and workforce development for each invaluable primary care clinical practitioner.

Catatonic syndrome: importance of detection and treatment with lorazepam.

BACKGROUND: A resurgence of interest has led to renewed attempts to clarify the concept and treatment of catatonia. METHOD: A large prospective study was conducted to estimate the incidence of catatonic syndrome in 138 consecutive psychiatric patients admitted to a general hospital in India, to demarcate the common symptom presentations and its response to intravenous benzodiazepines. Patients were screened using the Bush Francis Catatonia Screening Instrument. Patients with two or more signs on the Instrument were subsequently administered intravenous lorazepam and their response was rated on the Bush Francis Catatonia Rating Scale. RESULTS: Catatonic syndrome was found in 11% of patients with a wide variety of diagnoses, especially schizophrenia. Mutism (87.5% incidence) was the most common symptom. A significant proportion (93%) of these patients showed a marked immediate response to lorazepam, with 75% showing sustained improvement. CONCLUSIONS: Catatonic syndrome is common, often undiagnosed, and quickly responsive to treatment, irrespective of the diagnosis. It needs to be identified and actively treated with benzodiazepines to minimize distress, and facilitate diagnosis and treatment. Most patients also need additional treatment for the underlying psychiatric condition.

A Purpose-Driven Fourth Year of Medical School.

The fourth year of medical school has been repeatedly found to be ineffective, and concerns exist about its purpose and academic quality, as well as grade inflation. Since Flexner, the purpose of undergraduate medical training has moved from readiness for independent practice to readiness for postgraduate training. However, training directors report that medical graduates are inadequately prepared to enter residency. The authors propose a fourth year with two components: first, a yearlong, longitudinal ambulatory experience of at least three days each week on an interprofessional team with consistent faculty supervision and mentoring, increasing independence, and a focus on education; and second, rigorous clinical-scales-based assessment of meaningful outcomes.In the proposed model, the medical student has generous time with a limited panel of patients, and increasing autonomy, with faculty moving from supervising physicians to collaborating physicians. There is regular assessment and formative feedback. This more independent, longitudinal clinical experience uniquely allows assessment of the most meaningful work-based performance outcomes-that is, patient outcomes assessed by validated clinical scales. The proposed fourth year will require a realignment of resources and faculty time; however, models already exist. Barriers and possible solutions are discussed.A purpose-driven, assessment-rich fourth year with patient and supervisor continuity will provide real-world experience, making medical graduates more competent and confident on the first day of residency. Use of clinical scales will also allow educators new confidence that the performance-based competence of these more experienced and expert graduates leads to demonstrable collaboration, healing, and good patient outcomes.

Psychiatric morbidity following motor vehicle crashes: a pilot study from India.

BACKGROUND: Motor vehicle crashes can result in significant posttraumatic psychiatric morbidity. While the psychological impact of major disasters has been extensively studied in developing nations, psychological distress resulting from personal disasters such as road traffic crashes is sadly lacking. METHOD: Thirty inpatients who had been involved in a motor vehicle crash, either as a driver, passenger, or pedestrian, were assessed for psychiatric morbidity using the Hospital Anxiety and Depression Scale and the Impact of Events Scale. We also studied the influence of various sociodemographic factors and peritraumatic emotional experiences on the development of psychological symptoms. RESULTS: Of the 30 patients, 57% had anxiety or depressive symptoms, 30% had an anxiety or depressive disorder, and 20% had posttraumatic stress disorder. It was also observed that peritraumatic emotions seemed to determine the type and severity of psychiatric symptoms that patients experienced. CONCLUSIONS: This study found that more than half of the victims of motor vehicle crashes in the sample suffered from some form of psychiatric morbidity. With rising industrialization and motorization in developing countries, the number of victims of motor vehicle crashes is bound to increase. Adequate attention to psychiatric interventions in the provision of emergency and trauma services could help prevent significant disability.

The art & science of prescribing.

When medical interventions fail, it's often because there is no mutually agreed-upon regimen for the patient to follow. The authors provide evidence-based strategies to improve adherence, plus an easy-to-use prescribing checklist.

Prophylaxis of antipsychotic-induced extrapyramidal side effects in east Indians: cultural practice or biological necessity?

OBJECTIVE: Although still controversial, as early as 1989, the World Health Organization recommended that antipsychotic agents should be initiated without routinely adding anticholinergic drugs prophylactically. However, combined treatment with antipsychotics and anticholinergic agents is the norm in India. The goal of this study was to investigate whether Indians are more susceptible to extrapyramidal side effects (EPS) or if the practice of routinely adding an anticholinergic agent to an antipsychotic is overly cautious and wasteful. METHOD: 75 consecutive patients started on conventional antipsychotics were repeatedly evaluated over 2 months on a standardized EPS scale, the abbreviated Simpson-Angus scale. RESULTS: Of 71 subjects who completed the study, 68 (96%) suffered EPS while receiving 2-13 mg/day of haloperidol equivalents, with 70% of EPS present by day 5 and 90% by day 10. The most common symptoms were tremor (49%), cogwheel rigidity (40%), and acute dsytonic reaction (34%). Routine clinical care detected 49% of the EPS, patients volunteered a complaint 19% of the time, and relatives reported EPS in 7% of patients. CONCLUSION: Since patients of Indian origin are prone to suffer EPS when taking conventional antipsychotic drugs, initial prophylaxis with antiparkinson agents should perhaps be more carefully considered on a routine basis. Even among atypicals, agents with the least potential to cause EPS should be favored. In all patients treated with antipsychotics, it is imperative to ask directly about and carefully examine for EPS, because few patients will volunteer their complaints.

Comparing the side effect profile of the atypical antipsychotics.

Typical antipsychotics exert their effect by blocking post-synaptic dopaminergic receptors; blockade of the mesolimbic and mesocortical pathways are therapeutic and help reduce positive psychotic symptoms but blockade of the nigro-striatal pathway produces extrapyramidal side effects (EPSE). Post clozapine, the Food and Drug Administration (FDA) has approved the use of four newer atypical antipsychotics; risperidone, olanzapine, quetiapine and ziprasidone for the treatment of schizophrenia. Because of their dual serotonin and dopamine receptor blocking abilities, atypical antipsychotics have greater efficacy (especially for negative symptoms) and fewer EPSE when compared to the typical antipsychotics. Given the lack of studies directly comparing these agents, we used the Physician Desk Reference (PDR) to calculate the treatment emergent placebo adjusted side effects for these atypical antipsychotics. The results are then presented in an easy to read table. To the best of our knowledge, this is the first comparison study involving these four newer antipsychotic agents.

Components of Critical Decision Making and ABSITE Assessment: Toward a More Comprehensive Evaluation.

RATIONALE: Accurate assessment of resident competency is a fundamental requisite to assure the training of physicians is adequate. In surgical disciplines, structured tests as well as ongoing evaluation by faculty are used for evaluating resident competency. Although structured tests evaluate content knowledge, faculty ratings are a better measure of how that knowledge is applied to real-world problems. In this study, we sought to explore the performance of surgical residents in a simulation exercise (strategic management simulations [SMS]) as an objective surrogate of real-world performance. METHODS: Forty surgical residents participated in the SMS simulation that entailed decision making in a real-world-oriented task situation. The task requirements enable the assessment of decision making along several parameters of thinking under both crisis and noncrisis situations. Performance attributes include "simpler" measures of competency (activity level), intermediate categories (information management and emergency responses) to complex measures (breadth of approach and strategy). Scores obtained in the SMS were compared with the scores obtained on the American Board of Surgery In-Training Examination (ABSITE). RESULTS: The data were intercorrelated and subjected to a multiple regression analysis with ABSITE as the dependent variable and simulation scores as independent variables. Using a 1-tail test analysis, only 3 simulation variables correlated with performance on ABSITE at the .01 level (ie, basic activity, focused activity, task orientation). Other simulation variables showed no meaningful relationships to ABSITE scores at all. CONCLUSIONS: The more complex real-world-oriented decision-making parameters on SMS did not correlate with ABSITE scores. We believe that techniques such as the SMS, which focus on critical thinking, complement assessment of medical knowledge using ABSITE. The SMS technique provides an accurate measure of real-world performance and provides objective validation of faculty ratings.

Treating common psychiatric disorders associated with attention-deficit/hyperactivity disorder.

Attention-deficit/hyperactivity disorder (ADHD) often occurs along with other psychiatric disorders, with estimated comorbidity rates of 50--90%. Comorbidity greatly influences presentation, diagnosis and prognosis, complicates treatment and significantly increases the morbidity and disease burden of ADHD. Commonly co-occurring psychiatric disorders are disruptive behavior disorder, anxiety, depression, bipolar disorder and substance use disorders. This article provides a brief review of effective strategies for treating the most common psychiatric disorders associated with ADHD. This paper also discusses knowledge gaps in the understanding of treatment of comorbid disorders associated with ADHD, and directions for future research.