A survey of personnel and services offered in 32 outpatient US clozapine clinics.

BACKGROUND: Clozapine clinics can facilitate greater access to clozapine, but there is a paucity of data on their structure in the US. METHODS: A 23-item survey was administered to participants recruited from the SMI Adviser Clozapine Center of Excellence listserv to understand characteristics of clozapine clinics. RESULTS: Clozapine clinics (N = 32) had a median caseload of 45 (IQR = 21-88) patients and utilized a median of 5 (IQR = 4-6) interdisciplinary roles. The most common roles included psychiatrists (100%), pharmacists (65.6%), nurses (65.6%), psychiatric nurse practitioners (53.1%), and case managers (53.1%). The majority of clinics outreached to patients who were overdue for labs (78.1%) and had access to on-site phlebotomy (62.5%). Less than half had on call services (46.9%). CONCLUSIONS: In this first systematic description of clozapine clinics in the US, there was variation in the size, staffing, and services offered. These findings may serve as a window into configurations of clozapine teams.

Gaps in preparedness of clergy and healthcare providers to address mental health needs of returning service members.

To elucidate gaps in the preparedness of clergy and healthcare providers to care for service members (SM) with deployment-related mental health needs. Participants identified clinically relevant symptoms in a standardized video role play of a veteran with deployment-related mental health needs and discussed their preparedness to deal with SM. Clergy members identified suicide and depression most often, while providers identified difficulty sleeping, low energy, nightmares and irritability. Neither clergy nor providers felt prepared to minister to or treat SM with traumatic brain injury. Through a mixed methods approach, we identified gaps in preparedness of clergy and healthcare providers in dealing with the mental health needs of SM.

Simulation-based ongoing professional practice evaluation in psychiatry: a novel tool for performance assessment.

BACKGROUND: Ongoing professional practice evaluation (OPPE) activities consist of a quantitative, competency-based evaluation of clinical performance. Hospitals must design assessments that measure clinical competencies, are scalable, and minimize impact on the clinician's daily routines. A psychiatry department at a large academic medical center designed and implemented an interactive Web-based psychiatric simulation focusing on violence risk assessment as a tool for a departmentwide OPPE. METHODS: Of 412 invited clinicians in a large psychiatry department, 410 completed an online simulation in April-May 2012. Participants received scheduled e-mail reminders with instructions describing how to access the simulation. Using the Computer Simulation Assessment Tool, participants viewed an introductory video and were then asked to conduct a risk assessment, acting as a clinician in the encounter by selecting actions from a series of drop-down menus. Each action was paired with a corresponding video segment of a clinical encounter with a standardized patient. Participants were scored on the basis of their actions within the simulation (Measure 1) and by their responses to the open-ended questions in which they were asked to integrate the information from the simulation in a summative manner (Measure 2). RESULTS: Of the 410 clinicians, 381 (92.9%) passed Measure 1,359 (87.6%) passed Measure 2, and 5 (1.2%) failed both measures. Seventy-five (18.3%) participants were referred for focused professional practice evaluation (FPPE) after failing either Measure 1, Measure 2, or both. CONCLUSIONS: Overall, Web-based simulation and e-mail engagement tools were a scalable and efficient way to assess a large number of clinicians in OPPE and to identify those who required FPPE.

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.

The psychodynamics of transference--a virtual reality model.

OBJECTIVE: Virtual reality is not only being utilized increasingly as an enhancement for diagnosis and treatment of psychiatric illness, but it also can be used to model theories, generate hypotheses, and provide a new context for teaching psychodynamic therapy. Here we describe the use of an online virtual world--Second Life--as a heuristic tool for understanding and teaching a key psychoanalytic concept, transference. METHODS: Using an extended vignette to illustrate the results of the modeling process, we explore teaching the vicissitudes of object relationships by means of analogs in virtual reality. RESULTS: Simple reframing operations demonstrate how traditional dynamic theories of psychiatric treatment can be brought to life in simulations using modern computer technology. CONCLUSIONS: Virtual worlds offer a helpful analogy in teaching complex psychoanalytic concepts, such as transference.

Psychogenic movement disorders and motor conversion: a roadmap for collaboration between neurology and psychiatry.

BACKGROUND: There are a host of vague terms to describe psychologically-mediated symptoms that mimic neurological disease, such as "functional," "non-organic," "psychogenic," or "medically unexplained." None of these terms has a direct translation in psychiatric classification, and psychiatrists are often faced with patients who do not believe in a psychological origin for their symptoms. OBJECTIVE: Within the framework of psychogenic movement disorders, we discuss the roadblocks to effective collaboration and treatment in these patients and the current state of the literature regarding diagnosis and treatment. RESULTS: We describe the approach to these patients from the perspective of neurology and psychiatry, illustrating the differences in terminology and categorization. CONCLUSION: Psychogenic movement disorders represent a unique opportunity for these fields to collaborate in the care of a potentially curable but significantly disabling disorder.

Medical professionalism: a tale of two doctors.

The AMA's social media guidelines provide physicians with some basic rules for maintaining professional boundaries when engaging in online activities. Left unanswered are questions about how these guidelines are to be implemented by physicians of different generations. By examining the issues of privacy and technological skill through the eyes of digital natives and digital immigrants, the challenges associated with medical e-professionalism become clear.

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.

Supporting the Mental Health Workforce During and After COVID-19.

The COVID-19 pandemic has catalyzed structural changes in the public mental health sector, including a shift to telehealth and telesupervision, financial strain for community mental health organizations and clinicians, and risk of burnout among clinicians and staff. This Open Forum considers how technical assistance organizations have supported community mental health providers in adapting to these changes. Moving forward, knowledge gained through this work can help to build the body of practice-based evidence to inform future technical assistance activities in a postpandemic world.

New Tools for Implementing Evidence-Based Care for Serious Mental Illness.

More than 11 million adults in the United States have a serious mental illness. Outcomes for these illnesses are good when appropriate treatments are received; however, rates of delivery and utilization of evidence-based care for this population are moderate to low. This article introduces SMI Adviser, a national initiative, supported by the Substance Abuse and Mental Health Services Administration, to advance the use of evidence-based practices and delivery of patient-centered care for the population with serious mental illness. SMI Adviser offers free technical assistance to clinicians caring for this population through accredited educational opportunities, vetted resources, and on-demand consultations.

Well-Being, Burnout, and Depression Among North American Psychiatrists: The State of Our Profession.

OBJECTIVE: The authors examined the prevalence of burnout and depressive symptoms among North American psychiatrists, determined demographic and practice characteristics that increase the risk for these symptoms, and assessed the correlation between burnout and depression. METHODS: A total of 2,084 North American psychiatrists participated in an online survey, completed the Oldenburg Burnout Inventory (OLBI) and the Patient Health Questionnaire-9 (PHQ-9), and provided demographic data and practice information. Linear regression analysis was used to determine factors associated with higher burnout and depression scores. RESULTS: Participants' mean OLBI score was 40.4 (SD=7.9) and mean PHQ-9 score was 5.1 (SD=4.9). A total of 78% (N=1,625) of participants had an OLBI score ≥35, suggestive of high levels of burnout, and 16.1% (N=336) of participants had PHQ-9 scores ≥10, suggesting a diagnosis of major depression. Presence of depressive symptoms, female gender, inability to control one's schedule, and work setting were significantly associated with higher OLBI scores. Burnout, female gender, resident or early-career stage, and nonacademic setting practice were significantly associated with higher PHQ-9 scores. A total of 98% of psychiatrists who had PHQ-9 scores ≥10 also had OLBI scores >35. Suicidal ideation was not significantly associated with burnout in a partially adjusted linear regression model. CONCLUSIONS: Psychiatrists experience burnout and depression at a substantial rate. This study advances the understanding of factors that increase the risk for burnout and depression among psychiatrists and has implications for the development of targeted interventions to reduce the high rates of burnout and depression among psychiatrists. These findings have significance for future work aimed at workforce retention and improving quality of care for psychiatric patients.

The Role of Digital Navigators in Promoting Clinical Care and Technology Integration into Practice.

As the role of technology expands in healthcare, so does the need to support its implementation and integration into the clinic. The concept of a new team member, the digital navigator, able to assume this role is introduced as a solution. With a digital navigator, any clinic today can take advantage of digital health and smartphone tools to augment and expand existing telehealth and face to face care. The role of a digital navigator is suitable as an entry level healthcare role, additional training for an experienced clinician, and well suited to peer specialists. To facilitate the training of digital navigators, we draw upon our experience in creating the role and across health education to introduce a 10-h curriculum designed to train digital navigators across 5 domains: (1) core smartphone skills, (2) basic technology troubleshooting, (3) app evaluation, (4) clinical terminology and data, and (5) engagement techniques. This paper outlines the curricular content, skills, and modules for this training and features a rich online supplementary Appendix with step by step instructions and resources.

Medical student involvement in website development.

BACKGROUND: The digital management of educational resources and information is becoming an important part of medical education. AIMS: At Vanderbilt University School of Medicine, two medical students sought to create a website for all medical students to act as each student's individual homepage. METHOD: Using widely available software and database technology, a highly customized Web portal, known as the VMS Portal, was created for medical students. Access to course material, evaluations, academic information, and community assets were customized for individual users. Modular features were added over the course of a year in response to student requests, monitoring of usage habits, and solicitation of direct student feedback. RESULTS: During the first 742 days of the VMS Portal's release, there were 209,460 student login sessions (282 average daily). Of 348 medical students surveyed (71% response rate), 84% agreed or strongly agreed that 'consolidated student resources made their lives easier' and 82% agreed or strongly agreed that their needs were represented by having medical students design and create the VMS Portal. CONCLUSION: In the VMS Portal project, medical students were uniquely positioned to help consolidate, integrate, and develop Web resources for peers. As other medical schools create and expand digital resources, the valuable input and perspective of medical students should be solicited.

Lifelong menstrual histories are typically erratic and trending: a taxonomy.

OBJECTIVE: Menstrual cycles are composites of complex events; the data describing them are correspondingly rich. We seek to quantitatively represent menstrual histories from menarche to menopause and to evaluate the clinical belief that regular and stable cycle lengths are the most normative histories. DESIGN: Using prospective data from the Tremin Trust, we classified the menstrual histories of 628 women as very stable (type I), stable but with greater variability in cycle lengths (type II), oscillating and erratic with a downward trend in cycle length (type III), oscillating and erratic with no downward trend in cycle length (type IV), or highly erratic and variable (type V). Classification criteria were created by examining basic summary statistics of menstrual cycle lengths. Specifically, we identified key features describing variability of median cycle length, the mean of the interquartile range, the consistency of the interquartile range, the slope of median cycle lengths, and the number of stable 5-year intervals between ages 15 and 45+. RESULTS: We present the first characterization of full menstrual histories. Our taxonomy captures the essential features of menstrual bleeding patterns for a heterogeneous population. Persistently stable histories (types I and II) were seen in only 28% of the women; erratic histories (types III through V) characterized 72%. When examining all participants, significant differences were seen in age at menarche (P < 0.05), age at menopause (P < 0.01), and number of births (P < 0.01) between these stable and erratic groups. CONCLUSIONS: Although clinicians have traditionally thought of "normal" menstrual histories as being regular and stable, the distribution of women in our five categories suggest that variable histories are most common. Clinically, these results may suggest the need for a paradigm shift in what gynecologists view as normal and abnormal menstrual cycle histories.

Chronic versus episodic irritability in youth: a community-based, longitudinal study of clinical and diagnostic associations.

OBJECTIVE: Irritability is both a normal developmental phenomenon and a common psychiatric symptom in children. In psychiatric nosology, a distinction is made between chronic and episodic irritability. This study examines the validity of this distinction. METHODS: A sample of 776 youths received Diagnostic and Statistical Manual of Mental Disorders (DSM)-based structured interviews at three time points. Questions regarding episodic and chronic irritability were used to create scales measuring these constructs; associations with age, gender, and diagnosis were examined. RESULTS: Episodic and chronic irritability differed in their associations with age. The longitudinal stability within irritability type was stronger than between types. In longitudinal analyses, chronic irritability at time 1 (mean age 13.8 +/- 2.6 years) predicted attention deficit/ hyperactivity disorder at time 2 (mean age 16.2 +/- 2.8 years) and major depression at time 3 (mean age 22.1 +/- 2.7 years). Episodic irritability at time 1 predicted simple phobia and mania at time 2. CONCLUSIONS: Episodic and chronic irritability in adolescents appear to be stable, distinct constructs. Further research is needed to elucidate the longitudinal associations of each with specific psychiatric diagnoses.

Deficits on a probabilistic response-reversal task in patients with pediatric bipolar disorder.

OBJECTIVE: Patients with bipolar disorder become hyperhedonic when manic and anhedonic when depressed; therefore, it is important to test whether patients with bipolar disorder show deficits on behavioral paradigms exploring reward/punishment mechanisms. METHOD: A probabilistic response-reversal task was administered to 24 bipolar children and 25 comparison subjects. RESULTS: Patients made more errors during probabilistic reversal, took longer to learn the new reward object, and were less likely to meet the learning criterion. CONCLUSIONS: Children with bipolar disorder may have a reversal learning deficit.

Monitoring reproductive aging in a 5-year prospective study: aggregate and individual changes in steroid hormones and menstrual cycle lengths with age.

OBJECTIVE: We describe a 5-year prospective study of reproductive aging, and present analyses of steroid hormone and menstrual cycle changes with age. DESIGN: Participants were college-educated white women, primarily of northern European ancestry, recruited from the Tremin Research Program on Women's Health (n = 156, 25-58 years). In each of 5 consecutive years, they collected daily urine specimens for 6 months and recorded menstrual bleeds for all months. Urine specimens were assayed for estrone-3-glucuronide (E1G) and pregnanediol-3-glucuronide (PDG), urinary metabolites of estradiol and progesterone. Using multilevel models, we estimated hormone and cycle-length trajectories for individual women and within- and between-woman variance by age. RESULTS: At the aggregate level, PDG declined beginning in the 30s, E1G increased into the 40s before declining, and cycle length became more variable with age. Individual-level models revealed substantial hormonal variation across women, in both absolute levels and rates of change. Most women showed declining E1G by the late 40s, declining PDG in the 30s, and increasing mean cycle length in the 40s. Hormonal variation decreased with age; cycle length variation decreased and then increased. Within individual women, cycle lengths were highly variable while hormone levels were more stable. Women differed more from each other in hormone levels than for cycle lengths. CONCLUSIONS: Aggregate-level analyses show general changes in steroid hormones and cycle length but cannot show variation within and across women. Individuals' cycle lengths were too variable to predict hormone levels. Clinicians should obtain more data on individual women's hormonal patterns when determining fertility or menopause treatments.

Autism spectrum traits in children with mood and anxiety disorders.

The autism spectrum disorders (ASDs) can present with symptoms commonly found in mood and anxiety disorders. The Social Communication Questionnaire (SCQ), Children's Communication Checklist (CCC-2), and the Social Reciprocity Scale (SRS) were used to screen children in a mood disorders research clinic setting for symptoms of ASD. Ninety-three patients (mean age, 12.7 +/- 2.8 years; percent male, 63%) completed at least one scale, and 50 children completed all three. The prevalence of those screening positive for a possible ASD on one instrument was 62% and on all three measures was 8%. Fifty-seven percent (n = 21/37; odds ratio, 4.59 [95% confidence interval (CI) = 1.40-15.11]) of those scoring in the "ASD-likely" range on the SRS scored in that range on the CCC-2. Only 16% (n = 6/37; odds ratio, not significant (NS)) of those scoring in the ASD-likely range on the SRS, and 14% (n = 5/37; odds ratio, NS) of those scoring in the ASD-likely range on the CCC-2, scored similarly on the SCQ. These results demonstrate a need to develop valid and reliable instruments to screen for ASDs in children presenting outside of ASD clinics.