Immediate psychological distress in quarantined patients with COVID-19 and its association with peripheral inflammation: A mixed-method study.

Since the end of 2019, Corona Virus Disease 2019 (COVID-19) has been the cause of a worldwide pandemic. The mental status of patients with COVID-19 who have been quarantined and the interactions between their psychological distress and physiological levels of inflammation have yet to be analyzed. Using a mixed-method triangulation design (QUAN + QUAL), this study investigated and compared the mental status and inflammatory markers of 103 patients who, while hospitalized with mild symptoms, tested positive with COVID-19 and 103 matched controls that were COVID-19 negative. The severity of depression, anxiety, and post-traumatic stress symptoms (PTSS) was measured via an on-line survey. Using a convenience sampling technique, qualitative data were collected until the point of data saturation. In addition, a semi-structured interview was conducted among five patients with COVID-19. Peripheral inflammatory markers were also collected in patients, both at baseline and within ± three days of completing the on-line survey. Results revealed that COVID-19 patients, when compared to non-COVID controls, manifested higher levels of depression (P < 0.001), anxiety (P < 0.001), and post-traumatic stress symptoms (P < 0.001). A gender effect was observed in the score of "Perceived Helplessness", the subscale of PSS-10, with female patients showing higher scores compared to male patients (Z = 2.56, P = 0.010), female (Z = 2.37, P = 0.018) and male controls (Z = 2.87, P = 0.004). Levels of CRP, a peripheral inflammatory indicator, correlated positively with the PHQ-9 total score (R = 0.37, P = 0.003, Spearman's correlation) of patients who presented symptoms of depression. Moreover, the change of CRP level from baseline inversely correlated with the PHQ-9 total score (R = -0.31, P = 0.002), indicative of improvement of depression symptoms. Qualitative analysis revealed similar results with respect to patient reports of negative feelings, including fear, guilt, and helplessness. Stigma and uncertainty of viral disease progression were two main concerns expressed by COVID-19 patients. Our results indicate that significant psychological distress was experienced by hospitalized COVID-19 patients and that levels of depressive features may be related to the inflammation markers in these patients. Thus, we recommend that necessary measures should be provided to address depression and other psychiatric symptoms for COVID-19 patients and attention should be paid to patient perceived stigma and coping strategies when delivering psychological interventions.

Skills-Based Psychotherapy Training for Inpatient Psychiatry Residents: a Needs Assessment and Evaluation of a Pilot Curriculum.

OBJECTIVE: The study's objectives were to assess the psychotherapy interests and needs of psychiatry residents, to develop a psychotherapy didactic curriculum for psychiatry residents on the inpatient service, and to evaluate residents' self-reported understanding and confidence with skills-based interventions. METHODS: Psychiatry residents within a major metro region in the Northeast were asked if they would voluntarily participate in a survey to assess their interest and skills. Based on the results of this survey, the authors devised an 8-week course for seventeen residents on the inpatient unit. Topics included general cognitive behavioral therapy (CBT), sleep hygiene, behavioral activation, dialectical behavioral therapy (DBT), mind-body skills, and motivational interviewing. Residents completed post-course questionnaires on comprehension and confidence in providing psychotherapy skills using 5-point Likert scales. RESULTS: Participants (N = 39) reported a strong interest in learning psychotherapy and in education focused on inpatient skills-based interventions. At the end of the course, 12/17 (70.6%) participants provided feedback to indicate that 9/12 (75%) respondents experienced increased confidence in therapy skills, 10/12 (83.3%) reported a basic understanding of skills-based psychotherapy, and 10/12 (83.4%) believed they could teach at least one new technique. CONCLUSION: Psychiatry residents in this study overwhelmingly requested additional training focused on skills relevant to inpatient service, and the curriculum the authors developed led to a subjective self-reported understanding of and confidence in providing these psychotherapy skills on the inpatient unit. These very preliminary results suggest that provision of increased skills-based psychotherapy training for inpatient psychiatry residents is important and beneficial within resident education.

Correction to: Recommendations for the use of ECT in pregnancy: literature review and proposed clinical protocol.

The name of Heather Burrell Ward was incorrectly captured.

Recommendations for the use of ECT in pregnancy: literature review and proposed clinical protocol.

Psychiatric disorders are common in pregnancy, affecting 15-29% of pregnant women. Untreated depression has negative health consequences for mother and fetus. Electroconvulsive therapy (ECT) is an effective option for the treatment of severe depression, high suicide risk, catatonia, medication-resistant illness, psychotic agitation, severe physical decline, and other life-threatening conditions. To our knowledge, however, there is no literature that consolidates all the evidence on maternal and fetal risks associated with untreated depression, medications, and ECT then translating it into one cohesive protocol that could serve as a management guide and a source of reassurance to health-care providers involved in such practice. Hoping to facilitate ECT access to perinatal patients, the authors combined their multidisciplinary clinical experience (in perinatal psychiatry, neuropsychiatry and neuromodulation, and anesthesiology) at three different centers in the USA (Brigham and Women's Hospital/Harvard Medical School, The University of Chicago, and Brown University) with a careful and critical literature review and propose guidelines for the administration of ECT in pregnancy. A comprehensive review of the relevant literature regarding both ECT and psychotropic medications in pregnancy was performed, including meta-analyses of randomized controlled trials published in general medicine, anesthesiology, psychiatry, and obstetrics journals and guidelines. The indication and appropriateness of ECT in pregnancy must be carefully weighed against the risks of untreated maternal illness and those of alternative treatment options. The safety of ECT in pregnancy has been documented over the last 50 years. The adverse effects in pregnancy are similar to the risks of ECT in any individual. The most common risk to the mother is premature contractions and preterm labor, which occur infrequently and are not clearly caused by ECT. The rates of miscarriages were not significantly different from that of the general population. There have been no associations of ECT with congenital anomalies, either morphologic or behavioral, and no neurocognitive disturbances in the child. ECT is a reasonably safe and effective treatment alternative for management of many psychiatric disorders in pregnant patients. The authors provide recommendations for treatment modifications in pregnancy-based physiologic changes that occur during that period and consolidate them into a protocol that can assist clinicians in improving access and safety of ECT for pregnant patients.

Enhancing informed consent best practices: gaining patient, family and provider perspectives using reverse simulation.

BACKGROUND: Obtaining informed consent in the clinical setting is an important yet challenging aspect of providing safe and collaborative care to patients. While the medical profession has defined best practices for obtaining informed consent, it is unclear whether these standards meet the expressed needs of patients, their families as well as healthcare providers. The authors sought to address this gap by comparing the responses of these three groups with a standardised informed consent paradigm. METHODS: Piloting a web-based 'reverse' simulation paradigm, participants viewed a video showing a standardised doctor engaging in an informed consent discussion. The scenario depicted a simulated patient with psychotic symptoms who is prescribed an atypical antipsychotic medication. 107 participants accessed the simulation online and completed a web-based debriefing survey. RESULTS: Survey responses from patients, family members and healthcare providers indicated disparities in information retention, perception of the doctor's performance and priorities for required elements of the consent process. CONCLUSIONS: To enhance existing informed consent best practices, steps should be taken to improve patient retention of critical information. Adverse events should be described in the short-term and long-term along with preventative measures, and alternative psychosocial and pharmacological treatment options should be reviewed. Information about treatment should include when the medication takes therapeutic effect and how to safely maintain the treatment. The reverse simulation design is a model that can discern gaps in clinical practice, which can be used to improve patient care.

Postpartum Depression in Surgeons and Workplace Support for Obstetric and Neonatal Complication: Results of a National Study of US Surgeons.

BACKGROUND: Postpartum depression has well-established long-term adverse effects on maternal and infant health. Surgeons with rigorous operative schedules are at higher risk of obstetric complications, but they rarely reduce their workload during pregnancy. We evaluated whether lack of workplace support for work reductions during difficult pregnancies or after neonatal complications is associated with surgeon postpartum depression. STUDY DESIGN: An electronic survey was sent to practicing and resident surgeons of both sexes in the US. Female surgeons who had at least one live birth were included. Lack of workplace support was defined as: (1) disagreeing that colleagues/leadership were supportive of obstetric-mandated bedrest or time off to care for an infant in the neonatal intensive care unit; (2) feeling unable to reduce clinical duties during pregnancy despite health concerns or to care for an infant in the neonatal intensive care unit. Multivariate logistic regression was used to determine the association of lack of workplace support with postpartum depression. RESULTS: Six hundred ninety-two surgeons were included. The 441 (63.7%) respondents who perceived a lack of workplace support had a higher risk of postpartum depression than those who did not perceive a lack of workplace support (odds ratio 2.21, 95% CI 1.09 to 4.46), controlling for age, race, career stage, and pregnancy/neonatal complications. Of the surgeons with obstetric-related work restrictions, 22.6% experienced loss of income and 38.5% reported >$50,000 loss. CONCLUSION: Lack of workplace support for surgeons with obstetric or neonatal health concerns is associated with a higher risk of postpartum depression. Institutional policies must address the needs of surgeons facing difficult pregnancies to improve mental health outcomes and promote career longevity.

(In)Equality and Beyond: Achieving Justice in Gender-Affirming Hormone Initiation.

ABSTRACT: The World Professional Association for Transgender Health (WPATH) is an international organization that aims to advocate for transgender and gender-diverse (TGD) people by promoting safe and effective ways to access and deliver healthcare to maximize psychological health and well-being. One way this is achieved is through the WPATH's published Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, a set of guidelines for gender-affirming care that is based on the available science and expert consensus. In anticipation of the release of updated guidelines (Standards of Care Version 8) in 2022 the Radcliffe Institute for Advanced Study at Harvard University hosted an Exploratory Seminar in December 2021 that brought together experts from the United States, Mexico, and the United Kingdom to share knowledge across disciplines in order to propose revisions to the WPATH's updated guidelines. This article shares the workgroup's high-level consensus and recommendations.

Web-based simulation in psychiatry residency training: a pilot study.

BACKGROUND: Medical specialties, including surgery, obstetrics, anesthesia, critical care, and trauma, have adopted simulation technology for measuring clinical competency as a routine part of their residency training programs; yet, simulation technologies have rarely been adapted or used for psychiatry training. OBJECTIVE: The authors describe the development of a web-based computer simulation tool intended to assess physician competence in obtaining informed consent before prescribing antipsychotic medication to a simulated patient with symptoms of psychosis. METHOD: Eighteen residents participated in a pilot study of the Computer Simulation Assessment Tool (CSAT). Outcome measures included physician performance on required elements, pre- and post-test measures of physician confidence in obtaining informed consent, and levels of system usability. RESULTS: Data suggested that the CSAT increased physician confidence in obtaining informed consent and that it was easy to use. CONCLUSIONS: The CSAT was an effective educational tool in simulating patient-physician interactions, and it may serve as a model for use of other web-based simulations to augment traditional teaching methods in residency education.

Physicians' perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues.

CONTEXT: Peer monitoring and reporting are the primary mechanisms for identifying physicians who are impaired or otherwise incompetent to practice, but data suggest that the rate of such reporting is lower than it should be. OBJECTIVE: To understand physicians' beliefs, preparedness, and actual experiences related to colleagues who are impaired or incompetent to practice medicine. DESIGN, SETTING, AND PARTICIPANTS: Nationally representative survey of 2938 eligible physicians practicing in the United States in 2009 in anesthesiology, cardiology, family practice, general surgery, internal medicine, pediatrics, and psychiatry. Overall, 1891 physicians (64.4%) responded. MAIN OUTCOME MEASURES: Beliefs about and preparedness for reporting and experiences with colleagues who practice medicine while impaired or who are incompetent in their medical practice. RESULTS: Sixty-four percent (n = 1120) of surveyed physicians agreed with the professional commitment to report physicians who are significantly impaired or otherwise incompetent to practice. Nonetheless, only 69% (n = 1208) of physicians reported being prepared to effectively deal with impaired colleagues in their medical practice, and 64% (n = 1126) reported being so prepared to deal with incompetent colleagues. Seventeen percent (n = 309) of physicians had direct personal knowledge of a physician colleague who was incompetent to practice medicine in their hospital, group, or practice. Of those with this knowledge, 67% (n = 204) reported this colleague to the relevant authority. Underrepresented minorities and graduates of non-US medical schools were less likely than their counterparts to report, and physicians working in hospitals or medical schools were most likely to report. The most frequently cited reason for taking no action was the belief that someone else was taking care of the problem (19% [n = 58]), followed by the belief that nothing would happen as a result of the report (15% [n = 46]) and fear of retribution (12% [n = 36]). CONCLUSION: Overall, physicians support the professional commitment to report all instances of impaired or incompetent colleagues in their medical practice to a relevant authority; however, when faced with these situations, many do not report.

Catatonia Due to Tacrolimus Toxicity 16 Years After Renal Transplantation: Case Report and Literature Review.

Tacrolimus, a potent posttransplant immunosuppressant, has been associated with major neuropsychiatric complications, including catatonia and psychosis. We report a novel case of tacrolimus-induced encephalopathy that developed 16 years after renal transplantation while the drug was at a therapeutic level. Discontinuation of tacrolimus and switching to an alternative immunosuppressant resulted in significant clinical improvement over 1 week. Our experience illustrates the possibility of acute neurotoxicity from tacrolimus even when the patient has tolerated the drug for 16 years and drug levels are within the therapeutic range. This case also highlights the importance of collaboration between psychiatry and transplant clinicians.

Lurasidone Malabsorption Following Bariatric Surgery: A Case Report.

A significant segment of the United States adult population is obese. Bariatric surgery is one approach to weight loss when nonsurgical efforts have failed. In individuals with a body mass index ≥50, gastric reduction with duodenal switch is more effective than gastric bypass. More than half of bariatric surgery candidates report a history of mental illness and more than one third were taking at least one psychotropic medication at the time of surgery. Thus, the impact of surgery on absorption of psychiatric medications should be considered. Lurasidone, a second-generation antipsychotic used to treat schizophrenia and bipolar disorder, is recommended to be taken with food of at least 350 calories. We describe the case of a patient with incomplete response to lurasidone therapy in the year following a duodenal switch procedure. This case raises concern about the effect that the duodenal switch procedure may have on lurasidone absorption.

Longitudinal Urgent Care Psychiatry as a Unique Access Point for Underserved Patients.

OBJECTIVE: The authors sought to determine whether a walk-in psychiatry model with longitudinal follow-up capability could improve access for patients who traditionally miss appointments. METHODS: An urgent care clinic that offers treatment exclusively on a walk-in basis was opened within an adult psychiatry practice to accommodate patients who missed prior scheduled appointments. Electronic health records for patients who received an initial psychiatry evaluation at the practice during a 6-month period (N=355) were reviewed retrospectively to track the clinic's productivity and patient demographic characteristics. RESULTS: Eighty patients (23%) accessed their initial psychiatry encounters through the walk-in clinic. Medicaid recipients (odds ratio [OR]=1.89, 95% confidence interval [CI]=1.10-3.24) and individuals without a college degree (OR=1.86, 95% CI=1.04-3.32) were more likely than patients with other insurance carriers and those with a college degree, respectively, to access care through a walk-in encounter versus a scheduled appointment. CONCLUSIONS: Longitudinal walk-in psychiatry services can feasibly be offered through the longitudinal urgent care psychiatry model. This model may serve as a unique access point for patients from historically underserved groups.

Outcomes of a monitoring program for physicians with mental and behavioral health problems.

OBJECTIVE: Most states have programs that provide structured monitoring for physicians with substance use disorders (SUDs). In recent years, the Massachusetts Medical Society's Physician Health Services (PHS) program has used a similarly structured approach to monitor physicians with other mental and behavioral health (MBH) problems. The objective of this study was to determine the outcomes of the PHS monitoring programs for SUDs and MBH problems, compare their overall success rates, and identify correlates of success. METHOD: Data were extracted from the PHS administrative database for physicians presenting between January 1, 1993 and May 31, 2003. Variables included gender, age, specialty, type of monitoring contract (SUD vs MBH), and state licensing board involvement. Dates of contract openings and closings were used to categorize cases as successful completion, relapse, or other. RESULTS: Of 58 physicians with MBH contracts, 43 (74%) completed successfully, 7 (12%) relapsed, and 8 (14%) did not complete for other reasons. Of 120 total physicians with SUD contracts, 90 (75%) completed successfully, 10 (8%) relapsed, and 20 (17%) did not complete for other reasons. Successful completion of SUD contracts was significantly associated with licensing board involvement (84% vs 66%, p = 0.04). Survival analysis indicated that time to relapse was significantly shorter for women compared to men on both MBH and SUD contracts (log rank test for equality of survival distribution p < 0.001 for MBH and p = 0.001 for SUD). CONCLUSION: This study suggests that physicians with MBH problems can be monitored in a similar fashion as physicians with SUDs, and with similarly positive outcomes. However, greater attention should be given to services for women in physician health monitoring programs.

Problem doctors: is there a system-level solution?

Physician performance failures are not rare and pose substantial threats to patient welfare and safety. Few hospitals respond to such failures promptly or effectively. Failure to ensure the quality and safety of the performance of colleagues is a breach of medicine's fiduciary responsibility to the public. A major reason for this deficiency is the hospitals' lack of formal systems to monitor physician performance and to identify and correct shortcomings. To develop and implement these systems, hospitals need better performance measures and substantial expansion of external programs for assessment and remediation. This is a task well beyond the capacities of individual hospitals; a national effort is required. The authors call on the Federation of State Medical Boards, the American Board of Medical Specialties, and the Joint Commission on Accreditation of Healthcare Organizations (organizations that already bear a fiduciary responsibility for ensuring safe, competent care) to collaborate on developing better methods for measuring performance and to expand programs for helping practitioners who are deficient.

Reconciling America's Research Response to Binge Drinking among American Indians and Alaskan Natives.

Binge drinking among American Indians and Alaskan Natives is an acute health issue in the United States. The Radcliffe Institute for Advanced Study at Harvard University convened a one-day meeting with North American experts to identify key elements for developing research methodologies to measure treatment outcomes founded in Indigenous cultural ways of knowing. Three were identified: recognize culture as treatment, overcome Western interpretations of research, and apply culturally appropriate research methodologies. Common across the elements is respectful relationship development, which mirrors the efforts of the Canadian Truth and Reconciliation Commission that was established to address the destructive legacy of residential schools among First Nations. Reconciling America's research response to binge drinking among American Indians and Alaskan Natives requires a similar commitment.

The American Psychiatric Association's resource document on guidelines for psychiatric fitness-for-duty evaluations of physicians.

The psychiatric evaluation of a physician's fitness for duty is an undertaking that is both important to patients' well-being and to the physician-subject of the evaluation. It is necessary that psychiatrists who agree to perform such evaluations proceed in a careful and thorough manner. This document was developed to provide general guidance to the psychiatric evaluators in these situations. It was prepared by the American Psychiatric Association (APA) Council on Psychiatry and Law and Corresponding Committee on Physician Health, Illness, and Impairment, of which the authors are members. The Resource Document was approved by the APA Joint Reference Committee in June 2004. APA Resource Documents do not represent official policy of the American Psychiatric Association. This Resource Document was edited to conform to Journal style and has therefore been modified slightly from the original document approved by the APA.

Residents in distress: an exploration of assistance-seeking and reporting behaviors.

BACKGROUND: This study explores assistance-seeking and reporting behaviors in surgical residents faced with stressful circumstances. METHODS: Three surgical societies distributed a multiple choice, free-text response survey to residents. RESULTS: One hundred sixty-four residents (39% male) responded; 58% of women (43% men) were married; and 22% of men (7% women) were international medical graduates. Residents' dominant action to colleagues' concerning behavior was to approach him/her directly. Women were more likely to report colleagues' unpredictable behavior toward staff (28% vs 10%, P < .05), alcohol on breath at work (53% vs 32%, P = nonsignificant), and personal hygiene deterioration (15% vs 2%, P < .05) to an authority. Men were more likely to ignore frequent interpersonal conflicts and illnesses. CONCLUSIONS: Male and female surgery residents adopt different strategies in dealing with perceived distress in their colleagues. These impact their response to signs of impairment. Educators should consider sex while providing residents with an understanding of their role in the recognition of personal impairment and that of their peers.