Responding to moderate breaches in professionalism: an intervention for medical students.

Much has been written about how we understand, teach and evaluate professionalism in medical training. Less often described are explicit responses to mild or moderate professionalism concerns in medical students. To address this need, Baylor College of Medicine created a mechanism to assess professionalism competency for medical students and policies to address breaches in professional behavior. This article describes the development of an intervention using a guided reflection model, student responses to the intervention, and how the program evolved into a credible resource for deans and other educational leaders.

'The one truly serious philosophical problem': Ethical aspects of suicide.

Suicide is a major global public health problem with an estimated one million deaths every year. It is one of the most personal yet one of the most complex acts anyone can perform, as it goes to the very core of the concept of human existence and the meaning of life. The philosophical debate on suicide has spanned centuries with no clear answers. Juxtaposed within the various perspectives that suicide can be studied from is the ethical perspective that brings into sharp focus the conflict between personal autonomy and societal responsibility towards suicidal individuals. Mental health professionals find themselves in the midst of this conflict as they are assumed to have the responsibility to prevent suicide in their patients, while patients' responsibility towards themselves is frequently overlooked. Mental health professionals need to be aware of the ethical concerns that arise in the care of suicidal patients.

Lower effectiveness of divalproex versus valproic acid in a prospective, quasi-experimental clinical trial involving 9,260 psychiatric admissions.

OBJECTIVE: The authors examined clinical differences between divalproex sodium and generic immediate-release valproic acid. METHOD: This 6-year prospective, quasi-experimental clinical trial compared the effectiveness and tolerability of divalproex and valproic acid. The dependent variables were length of hospital stay, rehospitalization rate, and adverse drug reactions in 9,260 psychiatric admissions. RESULTS: Inpatients who initially received divalproex sodium had a 32.7% longer hospital stay and 3.8% higher readmission rate than did patients who initially received valproic acid. Initial treatment with divalproex prolonged length of stay by 30.3% in patients treated with divalproex and valproic acid during different admissions. After other variables were controlled by multiway analysis of variance, the hospital stay of patients who continued the initial medication was 15.2% longer (2.0 days) for divalproex than valproic acid. Switching medications was more common for valproic acid, partly because of study design. Medication intolerance occurred in approximately 6.4% more patients taking valproic acid than divalproex. However, switching from valproic acid to divalproex did not significantly prolong length of stay, over that for continuous divalproex, or increase the rehospitalization rate. CONCLUSIONS: Lower peak valproate concentrations with divalproex sodium may have enhanced tolerability but may also explain the lower effectiveness. Extended-release divalproex could lower effectiveness further and require higher doses. Thus, inpatients are better served by beginning with generic valproic acid and by changing to delayed-release divalproex only if intolerance occurs. This would save up to one-third of inpatient costs and two-thirds of a billion dollars yearly in medication costs.

Depression in pregnancy and the postpartum period: balancing adverse effects of untreated illness with treatment risks.

The author reviews the risks and benefits of untreated maternal depression during pregnancy and the postnatal period and its effects on the well-being of the mother and infant. She then discusses the significant role psychiatrists can play in detecting and managing maternal depression as a primary measure for preventing future child psychopathology. A literature search was conducted on PubMed to identify both preclinical and clinical studies concerning deleterious effects of maternal depression on offspring. Additional searches focused on available safety data concerning the use of antidepressants during pregnancy and lactation. Key search items included depression during pregnancy, postpartum depression, lactation, and antidepressants. Burgeoning evidence was found concerning the adverse effects of maternal depression on the developing fetus and infant in the perinatal period. No controlled studies on the safety of antidepressant use in pregnancy and lactation were found; therefore, case reports, and some retrospective and prospective case series, must serve as guidelines for the treating clinician. Each case of maternal depression needs to be evaluated on an individual basis and decisions about treatment interventions should involve both the patient and family. Maternal depression during pregnancy and the postnatal period is associated with a significant disease burden in that it affects not only the mother but may also have both short- and long-term effects on offspring. Therefore, early detection and management of maternal depression, of which perinatal screening of mothers is an important component, are warranted.

Global Child and Adolescent Mental Health: A Culturally Informed Focus.

There is no question that there is a significant burden of mental illness in children and families across the globe. Despite heightened awareness of the significance of global mental health and its determinants on public health, there is an increased need for innovative interventions, research, resources, and efforts devoted to this area. It has been clearly established that culture, in all of its complex dimensions and dynamics, is at the heart of this labor. In order to integrate culture into global mental health advocacy and solutions, a collaborative approach with flexibility in thinking and implementation must exist.

Child and Adolescent Psychiatry Training: A Global Perspective.

Training programs aim to produce child and adolescent psychiatry professionals who are competent at both clinical work as well as health promotion through teaching and research. Child psychiatry training programs not only offer training in teaching the clinical skills of the discipline of child and adolescent psychiatry but also strive to help with the development of professionalism, ethical behaviors, and leadership skills in their trainees. Ultimately, it is the children of the world who stand to gain by having a skilled work force that adheres to the highest global standards when it comes to the provision of mental health services.

Training child and adolescent psychiatrists to be culturally competent.

The changing face of the United States urges the field of child and adolescent psychiatry toward more culturally sensitive care. This article gives a comprehensive review of the history of cultural education, empirical findings that speak to its need, and the challenges that may be faced in the conception and implementation of a cultural competency curriculum. The American Academy of Child and Adolescent Psychiatry's model curriculum is presented to help child and adolescent residency programs design one that is specific to their resources and needs.