Helping psychiatry residents cope with patient suicide.

OBJECTIVE: Every clinical specialty has its own high risk patient challenges that threaten to undermine their trainees' professional identity, evolving sense of competence. In psychiatric training, it is patient suicide, an all-too frequently encountered consequence of severe mental illness that may leave the treating resident perplexed, guilt-ridden, and uncertain of their suitability for the profession. This study evaluates a patient suicide training program aimed at educating residents about patient suicide, common reactions, and steps to attenuate emotional distress while facilitating learning. METHODS: The intervention was selected aspects of a patient suicide educational program, "Collateral Damages,"-video vignettes, focused discussions, and a patient-based learning exercise. Pre- and post-survey results were compared to assess both knowledge and attitudes resulting from this educational program. Eight psychiatry residency training programs participated in the study, and 167 of a possible 240 trainees (response rate = 69.58 %) completed pre- and post-surveys. RESULTS: Knowledge of issues related to patient suicide increased after the program. Participants reported increased awareness of the common feelings physicians and trainees often experience after a patient suicide, of recommended "next" steps, available support systems, required documentation, and the role played by risk management. CONCLUSIONS: This patient suicide educational program increased awareness of issues related to patient suicide and shows promise as a useful and long overdue educational program in residency training. It will be useful to learn whether this program enhances patient care or coping with actual patient suicide. Similar programs might be useful for other specialties.

Teaching evidence-based approaches to suicide risk assessment and prevention that enhance psychiatric training.

This report describes one in a series of National Institute of Health (NIH) supported conferences aimed at enhancing the ability of leaders of psychiatry residency training to teach research literacy and produce both clinician-scholars and physician-scientists in their home programs. Most psychiatry training directors would not consider themselves research scholars or even well-schooled in evidence based practice. Yet they are the front line educators to prepare tomorrow's psychiatrists to keep up with, critically evaluate, and in some cases actually participate in the discovery of new and emerging psychiatric knowledge. This annual conference is meant to help psychiatry training directors become more enthusiastic, knowledgeable and pedagogically prepared to create research-friendly environments at their home institutions, so that more trainees will, in turn, become research literate, practice evidence-based psychiatry, and enter research fellowships and careers. The overall design of each year's meeting is a series of plenary sessions introducing participants to new information pertaining to the core theme of that year's meeting, integrated with highly interactive small group teaching sessions designed to consolidate knowledge and provide pragmatic teaching tools appropriate for residents at various levels of training. The theme of each meeting, selected to be a compelling and contemporary clinical problem, serves as a vehicle to capture training directors' attention while teaching relevant brain science, research literacy and effective pedagogy. This report describes the content and assessment of the 2011 annual pre-meeting, "Evidence-based Approaches to Suicide Risk Assessment and Prevention: Insights from the Neurosciences and Behavioral Sciences for use in Psychiatry Residency Training."

Psychological distress among religious nonbelievers: a systematic review.

Studies of religious belief and psychological health are on the rise, but most overlook atheists and agnostics. We review 14 articles that examine differences between nonbelievers and believers in levels of psychological distress, and potential sources of distress among nonbelievers. Various forms of psychological distress are experienced by nonbelievers, and greater certainty in one's belief system is associated with greater psychological health. We found one well-documented source of distress for nonbelievers: negative perceptions by others. We provide recommendations for improving research on nonbelievers and suggest a model analogous to Pargament's tripartite spiritual struggle to understand the stresses of nonbelief.

Bayesian imputation of COVID-19 positive test counts for nowcasting under reporting lag.

Obtaining up to date information on the number of UK COVID-19 regional infections is hampered by the reporting lag in positive test results for people with COVID-19 symptoms. In the UK, for 'Pillar 2' swab tests for those showing symptoms, it can take up to five days for results to be collated. We make use of the stability of the under reporting process over time to motivate a statistical temporal model that infers the final total count given the partial count information as it arrives. We adopt a Bayesian approach that provides for subjective priors on parameters and a hierarchical structure for an underlying latent intensity process for the infection counts. This results in a smoothed time-series representation nowcasting the expected number of daily counts of positive tests with uncertainty bands that can be used to aid decision making. Inference is performed using sequential Monte Carlo.

Improving local prevalence estimates of SARS-CoV-2 infections using a causal debiasing framework.

Global and national surveillance of SARS-CoV-2 epidemiology is mostly based on targeted schemes focused on testing individuals with symptoms. These tested groups are often unrepresentative of the wider population and exhibit test positivity rates that are biased upwards compared with the true population prevalence. Such data are routinely used to infer infection prevalence and the effective reproduction number, Rt, which affects public health policy. Here, we describe a causal framework that provides debiased fine-scale spatiotemporal estimates by combining targeted test counts with data from a randomized surveillance study in the United Kingdom called REACT. Our probabilistic model includes a bias parameter that captures the increased probability of an infected individual being tested, relative to a non-infected individual, and transforms observed test counts to debiased estimates of the true underlying local prevalence and Rt. We validated our approach on held-out REACT data over a 7-month period. Furthermore, our local estimates of Rt are indicative of 1-week- and 2-week-ahead changes in SARS-CoV-2-positive case numbers. We also observed increases in estimated local prevalence and Rt that reflect the spread of the Alpha and Delta variants. Our results illustrate how randomized surveys can augment targeted testing to improve statistical accuracy in monitoring the spread of emerging and ongoing infectious disease.

Older adults' preferences for religion/spirituality in treatment for anxiety and depression.

OBJECTIVES: To examine patient preferences for incorporating religion and/or spirituality into therapy for anxiety or depression and examine the relations between patient preferences and religious and spiritual coping styles, beliefs and behaviors. METHOD: Participants (66 adults, 55 years or older, from earlier studies of cognitive-behavioral therapy for late-life anxiety and/or depression in primary care) completed these measures by telephone or in-person: Geriatric Anxiety Inventory, Client Attitudes Toward Spirituality in Therapy, Patient Interview, Brief Religious Coping, Religious Problem Solving Scale, Santa Clara Strength of Religious Faith, and Brief Multidimensional Measure of Religiousness and Spirituality. Spearman's rank-order correlations and ordinal logistic regression examined religious/spiritual variables as predictors of preferences for inclusion of religion or spirituality into counseling. RESULTS: Most participants (77-83%) preferred including religion and/or spirituality in therapy for anxiety and depression. Participants who thought it was important to include religion or spirituality in therapy reported more positive religious-based coping, greater strength of religious faith, and greater collaborative and less self-directed problem-solving styles than participants who did not think it was important. CONCLUSION: For individuals like most participants in this study (Christians), incorporating spirituality/religion into counseling for anxiety and depression was desirable.

The aging physician with cognitive impairment: approaches to oversight, prevention, and remediation.

There are many important unanswered issues regarding the occurrence of cognitive impairment in physicians, such as detection of deficits, remediation efforts, policy implications for safe medical practice, and the need to safeguard quality patient care. The authors review existing literature on these complex issues and derive heuristic formulations regarding how to help manage the professional needs of the aging physician with dementia. To ensure safe standards of medical care while also protecting the needs of physicians and their families, state regulatory or licensing agencies in collaboration with state medical associations and academic medical centers should generate evaluation guidelines to assure continued high levels of functioning. The authors also raise the question of whether age should be considered as a risk factor that merits special screening for adequate functioning. Either age-related screening for cognitive impairment should be initiated or rigorous evaluation after lapses in standard of care should be the norm regardless of age. Ultimately, competence rather than mandatory retirement due to age per se should be the deciding factor regarding whether physicians should be able to continue their practice. Finally, the authors issue a call for an expert consensus panel to convene to make recommendations concerning aging physicians with cognitive impairment who are at risk for medical errors.

Healthcare Engagement as a Potential Source of Psychological Distress among People without Religious Beliefs: A Systematic Review.

Research into religion and mental health is increasing, but nonbelievers in terms of religion are often overlooked. Research has shown that nonbelievers experience various forms of psychological distress and that the negative perception of nonbelievers by others is a potential source of distress. This review builds on that research by identifying another potential source of psychological distress for nonbelievers: engagement with the healthcare system. Poor understanding of nonbelievers by healthcare professionals may lead to impaired communication in the healthcare setting, resulting in distress. Attempts by nonbelievers to avoid distress may result in different patterns of healthcare utilization. Awareness of these concerns may help healthcare providers to minimize distress among their nonbelieving patients.

Ethical considerations in the integration of religion and psychotherapy: three perspectives.

The authors maintain that the integration of religion in psychotherapy is, at best, problematic and requires a respect for boundaries, but that the integration of a nonreligious but spiritual psychotherapy consisting of the three elements identified above (attention to the person, not the disease, considering one's work as vocation, and the pursuit of empathic understanding) is a therapeutic necessity and an ethical duty. The authors speak with distinct voices in the three major sections of the article but come to remarkably similar conclusions: (1) the ability to inquire into the religious and spiritual life of patients is an important element of psychotherapeutic competency; (2) information about the religious and spiritual lives of patients often reveals extremely important information; (3) the inquiry process must communicate respect and curiosity for this dimension of the patient's life even (and perhaps especially) when the content is at variance from that of the therapist; and (4) there is significant potential for therapeutic abuse when the therapist communicates in a manner reflecting a personal agenda that abandons the principle of psychotherapeutic neutrality. One area of potential disagreement came as the authors considered the possibility of different combinations of faith disciplines and therapy in designated religious settings that all parties recognize as such. One author (G.P.M.) believes that such combinations in these settings may be ethically permissible. The other two authors are concerned about such combinations because of the powerful but covert factor of transference in healing relationships. The authors eventually decided that this question was beyond the scope of the article and limited themselves to discussions about psychotherapy in secular settings. They each advocate the systematic inclusion of spiritual assessment as a core competency for psychotherapy education. In a way similar to the exploration of any deeply personal dimension of human experience, integrating spiritual and religious dimensions of our patients' lives into their treatment requires consummate professionalism, the highest quality of knowledge, skills, and attitudes, and thorough grounding in a sophisticated biopsychosocial model.

Understanding and addressing religion among people with mental illness.

This article reviews recent advances in the domain of psychiatry and religion that highlight the double-edged capacity of religion to enhance or damage health and well-being, particularly among psychiatric patients. A large body of research challenges stereotyped views of religion as merely a defense or passive way of coping, and indicates that many people look to religion as a vital resource which serves a variety of adaptive functions, such as self-regulation, attachment, emotional comfort, meaning, and spirituality. There is, however, a darker side to religious life. Researchers and theorists have identified and begun to study problematic aspects of religiousness, including religiously-based violence and religious struggles within oneself, with others, and with the divine. Religious problems can be understood as a by-product of psychiatric illness (secondary), a source of psychiatric illness (primary), or both (complex). This growing body of knowledge underscores the need to attend more fully to the potentially constructive and destructive roles of religion in psychiatric diagnosis, assessment, and treatment. In fact, initial evaluative studies of the impact of spiritually integrated treatments among a range of psychiatric populations have shown promising results. The article concludes with a set of recommendations to advance future research and practice, including the need for additional psychiatric studies of people from diverse cultures and religious traditions.

Magnetic resonance imaging as a predictor of return to play following syndesmosis (high) ankle sprains in professional football players.

BACKGROUND: Syndesmosis ankle sprains cause greater disability and longer duration of recovery than lateral ankle sprains. OBJECTIVE: To describe the severity of syndesmosis sprains using several accepted magnetic resonance imaging (MRI) criteria and to assess the interrater reliability of diagnosing syndesmosis injury using these same criteria in professional American football players. HYPOTHESIS: There is a high degree of interrater reliability of MRI findings in American football players with syndesmosis ankle sprains. These radiographic findings will correlate with time lost to injury, indicating severity of the sprain. STUDY DESIGN: Uncontrolled retrospective review. METHODS: Player demographics and time lost to play were recorded among professional football players who had sustained a syndesmosis ankle sprain and underwent standardized ankle MRI. Each image was independently read by 3 blinded musculoskeletal radiologists. RESULTS: Seventeen players met study criteria. There was almost perfect agreement among the radiologists for diagnosing injury to the syndesmotic membrane; substantial agreement for diagnosing injury to the posterior inferior tibiofibular ligament (PITFL) and in determining the proximal extent of syndesmotic edema/injury; but only fair agreement for diagnosing injury to the anterior inferior tibiofibular ligament and in determining the width of syndesmotic separation. There was a significant correlation between the width of syndesmotic separation and time lost, but no significant correlation between individual syndesmotic ligament injury or proximal extent of syndesmotic edema/injury and time lost. CONCLUSION: While ankle MRI can identify syndesmotic disruption with a high degree of interobserver agreement, no association was demonstrated between the extent of injury on MRI and the time to return to play following a high ankle sprain. CLINICAL RELEVANCE: In athletes with suspected high ankle sprains, MRI may help confirm diagnosis or suggest alternative diagnoses when the syndesmotic supporting structures are intact. However, the severity of ligamentous and syndesmotic disruption on MRI cannot help predict recovery times.

A standards-based, peer-reviewed teaching award to enhance a medical school's teaching environment and inform the promotions process.

The authors provide the rationale, design, and description of a unique teaching award that has enhanced Baylor College of Medicine's teaching environment and become highly valued by the promotions and tenure (P&T) committee in determining a faculty member's readiness for promotion. This award is self-nominating and standards based. The primary purpose for development of the award was to provide the Baylor community and the P&T committee a method to understand and value the scholarship of teaching to the same degree that they understand and value the scholarship of discovery.The authors also present results from an internal evaluation of the program that included a survey and interviews. Between the inception of the award in 2001 and the internal review conducted in 2010, the award could have had an influence on the promotion of 130 of the recipients. Of the 130, 88 (65.6%) received this award before gaining their current rank (χ (1) = 16.3, P < .001). Stakeholders, including department chairs and members of the P&T committee, agreed that this award is valuable to those seeking promotion. Individual recipients stated that the award is good for the institution by encouraging reflection on teaching; increasing the recognition, importance, and value of teaching; encouraging the improvement of teaching skills; and providing a better understanding to others about what medical teachers really do. Of the 214 open-ended responses to survey questions of award recipients, more than half the comments were about the value of the award and its positive effect on promotion.

Learning from losing: ethical, psychoanalytic, and spiritual perspectives on managing the incremental losses of the distributed self in dementia.

The author describes his experiences making decisions about the care of his mother, who was suffering from dementia, and the profound effect this process had on him as a psychotherapist. As background, he first presents an overview of writings from Jerry M. Lewis, George Pollock, and George Vaillant on issues related to attachment, death, loss, and mourning. The author equates his experiences caring for his mother with a type of involuntary "continuing education" and describes the lessons he learned as he was faced with decisions about his mother's level of care and as he mourned the slow, piecemeal loss of her distributed self. A case vignette is presented to illustrate how the author applied the lessons he had learned in psychotherapy with a distressed patient caring for her aging mother. The article concludes with a summary of the clinical and ethical questions raised by this case and the author's experience with his mother and a discussion of principles that can help psychotherapists provide treatment for patients who are caring for family members with dementia. (Journal of Psychiatric Practice. 2011;17:41-48).

Role of the family in suicide prevention: an attachment and family systems perspective.

Suicide can be an act of despair, anger, or escape from intolerable pain associated with prior bonding disturbances within the family system, interpersonal loss, and current perceived lack of social support. Using a variety of online databases, the authors examined the research on the family's role in preventing suicide from an attachment and family systems perspective. They found relevant articles describing how to make use of family support in suicide prevention. From a study of the literature, the authors outline three new family concepts in suicide prevention: family cohesion, family adhesion, and formation of a new family. Therapists should use every familial resource to avoid premature closure and to expand perception of support options. The authors suggest specific practice recommendations to successfully involve families in suicide prevention based on the outlined family conceptual framework, and they recommend research investigation to determine empirical validation of these tentative formulations.