Internal Medicine Resident Addiction Training at the Veteran's Health Administration: A Qualitative Evaluation of Site Directors' Response to the 2022 ACGME Requirements.

BACKGROUND: Substance use disorders (SUDs) are prevalent in the USA yet remain dramatically undertreated. To address this care gap, the Accreditation Council for Graduate Medical Education (ACGME) approved revisions to the Program Requirements for Graduate Medical Education (GME) in Internal Medicine, effective July 1, 2022, requiring addiction medicine training for all internal medicine (IM) residents. The Veterans Health Administration (VHA) is a clinical training site for many academic institutions that sponsor IM residencies. This focus group project evaluated VHA IM residency site directors' perspectives about providing addiction medical education within VHA IM training sites. OBJECTIVE: To better understand the current state, barriers to, and facilitators of IM resident addiction medicine training at VHA sites. DESIGN: This was a qualitative evaluation based on semi-structured video-based focus groups. PARTICIPANTS: Participants were VHA IM site directors based at a VHA hospital or clinic throughout the USA. APPROACH: Focus groups were conducted using a semi-structured group interview guide. Two investigators coded each focus group independently, then met to create a final adjudicated coding scheme. Thematic analysis was used to identify key themes. KEY RESULTS: Forty-three participants from 38 VHA sites participated in four focus groups (average size: 11 participants). Six themes were identified within four pre-defined categories. Current state of training: most VHA sites offered no formal training in addiction medicine for IM residents. Barriers: addiction experts are often located outside of IM settings, and ACGME requirements were non-specific. Facilitators: clinical champions help support addiction training. Desired next steps: participants desired incentives to train or hire local champions and a pre-packaged didactic curriculum. CONCLUSIONS: Developing competent clinical champions and leveraging VHA addiction specialists from non-IM settings would create more addiction training opportunities for IM trainees at VHA sites. These insights can likely be applied to IM training at non-VHA sites.

DOES SCREENING WITH THE MDQ AND EPDS IMPROVE IDENTIFICATION OF BIPOLAR DISORDER IN AN OBSTETRICAL SAMPLE?

BACKGROUND: Women with bipolar disorder (BD) are at high risk for postpartum affective episodes and psychosis. Although validated screening tools are available for postpartum unipolar depression, few screening tools for hypomania/mania exist. Screening tools for BD in the postpartum period are essential for improving detection and planning appropriate treatment. We evaluated whether adding the Mood Disorders Questionnaire (MDQ) to the Edinburgh Postnatal Depression Scale (EPDS) increased the identification of BD in the early postpartum period. METHODS: Women (N = 1,279) who delivered a live infant and screened positive on the EPDS and/or MDQ at 4-6 weeks postbirth were invited to undergo an in-home Structured Clinical Interview for DSM-IV (SCID). RESULTS: Positive EPDS and/or MDQ screens occurred in 12% of the sample (n = 155). In home SCID diagnostic interviews were completed in 93 (60%) of the mothers with positive screens. BD was the primary diagnosis in 37% (n = 34). Women with BD screened positive on the EPDS and/or MDQ as follows: EPDS+/MDQ+ (n = 14), EPDS+/MDQ- (n = 17), and EPDS-/MDQ+ (n = 3). The MDQ identified 50% (17/34) of the women with BD and 6 additional cases of BD when the MDQ question regarding how impaired the mother perceived herself was excluded from the screen criterion. CONCLUSION: Addition of the MDQ to the EPDS improved the distinction of unipolar depression from bipolar depression at the level of screening in 50% of women with traditional MDQ scoring and by nearly 70% when the MDQ was scored without the impairment criterion.

Maternal-Infant interaction in women with unipoloar and bipolar depression.

BACKGROUND: One percent of women experience bipolar disorder and are likely to suffer from mood disorders during the postpartum period, potentially impacting interaction with their infants. The purpose of this study was to describe maternal-infant interactions in women with bipolar depression at 12 months postpartum and to compare interactions to women with unipolar depression and a control group. METHODS: Using a descriptive design, maternal-infant interactions in women with bipolar disorder (n=40) were videotaped, coded, and analyzed for maternal sensitivity and maternal-infant reciprocity and compared to maternal-infant interaction in women with unipolar depression (n=50) and women without depression (n=40). RESULTS: Women with bipolar depression had lower scores on both maternal sensitivity and infant reciprocity, but differences were nonsignificant. CONCLUSIONS: This research is the first study to examine maternal-infant interaction in women with bipolar disorder, and important trends were noted. Future research should examine maternal-infant interaction at earlier time periods.

Theoretical approaches to maternal-infant interaction: which approach best discriminates between mothers with and without postpartum depression?

OBJECTIVE: The purpose of this study was to determine which of the four common approaches to coding maternal-infant interaction best discriminates between mothers with and without postpartum depression. METHODS: After extensive training, four research assistants coded 83 three minute videotapes of maternal infant interaction at 12month postpartum visits. Four theoretical approaches to coding (Maternal Behavior Q-Sort, the Dyadic Mini Code, Ainsworth Maternal Sensitivity Scale, and the Child-Caregiver Mutual Regulation Scale) were used. Twelve month data were chosen to allow the maximum possible exposure of the infant to maternal depression during the first postpartum year. The videotapes were created in a laboratory with standard procedures. Inter-rater reliabilities for each coding method ranged from .7 to .9. The coders were blind to depression status of the mother. RESULTS: Twenty-seven of the women had major depressive disorder during the 12month postpartum period. Receiver operating characteristics analysis indicated that none of the four methods of analyzing maternal infant interaction discriminated between mothers with and without major depressive disorder. CONCLUSION: Limitations of the study include the cross-sectional design and the low number of women with major depressive disorder. Further analysis should include data from videotapes at earlier postpartum time periods, and alternative coding approaches should be considered. Nurses should continue to examine culturally appropriate ways in which new mothers can be supported in how to best nurture their babies.

Alcohol brief intervention for hospitalized veterans with hazardous drinking: protocol for a 3-arm randomized controlled efficacy trial.

BACKGROUND: Various hospital accreditation and quality assurance entities in the United States have approved and endorsed performance measures promoting alcohol brief intervention (BI) for hospitalized individuals who screen positive for unhealthy alcohol use, the spectrum of use ranging from hazardous use to alcohol use disorders. These performance measures have been controversial due to the limited and equivocal evidence for the efficacy of BI among hospitalized individuals. The few BI trials conducted with hospital inpatients vary widely in methodological quality. While the majority of these studies indicate limited to no effects of BI in this population, none have been designed to account for the most pervasive methodological issue in BI studies presumed to drive study findings towards the null: assessment reactivity (AR). METHODS/DESIGN: This is a three-arm, single-site, randomized controlled trial of BI for hospitalized patients at a large academic medical center affiliated with the U.S. Department of Veterans Affairs who use alcohol at hazardous levels but do not have an alcohol use disorder. Participants are randomized to one of three study conditions. Study Arm 1 receives a three-part alcohol BI. Study Arm 2 receives attention control. To account for potential AR, Study Arm 3 receives AC with limited assessment. Primary outcomes will include the number of standard drinks/week and binge drinking episodes reported in the 30-day period prior to a final measurement visit obtained 6 months after hospital discharge. Additional outcomes will include readiness to change drinking behavior and number of adverse consequences of alcohol use. To assess differences in primary outcomes across the three arms, we will use mixed-effects regression models that account for a patient's repeated measures over the timepoints and clustering within medical units. Intervention implementation will be assessed by: a) review of intervention audio recordings to characterize barriers to intervention fidelity; and b) feasibility of participant recruitment, enrollment, and follow-up. DISCUSSION: The results of this methodologically rigorous trial will provide greater justification for or against the use of BI performance measures in the inpatient setting and inform organizational responses to BI-related hospital accreditation and performance measures. TRIAL REGISTRATION: NCT01602172.

Does fetal exposure to SSRIs or maternal depression impact infant growth?

OBJECTIVE: The aim of this study was to compare the growth of infants born to women with antenatal major depressive disorder, either untreated or treated with selective serotonin reuptake inhibitor (SSRI) antidepressants, and infants born to a nondepressed, nonmedicated comparison group across the first year of life. METHOD: In this prospective observational study, pregnant women were evaluated at weeks 20, 30, and 36 of gestation, and mother and infant pairs were assessed at 2, 12, 26, and 52 weeks postpartum. Three nonoverlapping groups of women were defined according to their pregnancy exposures: 1) no SSRI and no depression (N=97), 2) SSRI (N=46), and 3) major depression without SSRI (N=31). Maternal demographic and clinical characteristics and newborn outcomes were compared across exposure groups. Infant weight, length, and head circumference were measured by a physician or physician's assistant who was blind to depression and SSRI exposure status at each postpartum time point. RESULTS: Both adjusted and unadjusted analyses revealed neither antenatal major depression nor SSRI exposure was significantly associated with infant weight, length, or head circumference relative to nonexposure to either. In addition, the interaction of group and prepregnancy body mass index was also evaluated, and no significant synergistic effect was identified. Similarly, no differential effect of group over time was observed for weight, length, or head circumference. CONCLUSIONS: In utero exposure to major depression or SSRI antidepressants did not affect infant growth with respect to weight, length, or head circumference from birth through 12 months of age.

Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings.

IMPORTANCE: The period prevalence of depression among women is 21.9% during the first postpartum year; however, questions remain about the value of screening for depression. OBJECTIVES: To screen for depression in postpartum women and evaluate positive screen findings to determine the timing of episode onset, rate and intensity of self-harm ideation, and primary and secondary DSM-IV disorders to inform treatment and policy decisions. DESIGN: Sequential case series of women who recently gave birth. SETTING: Urban academic women's hospital. PARTICIPANTS: During the maternity hospitalization, women were offered screening at 4 to 6 weeks post partum by telephone. Screen-positive women were invited to undergo psychiatric evaluations in their homes. MAIN OUTCOMES AND MEASURES: A positive screen finding was an Edinburgh Postnatal Depression Scale (EPDS) score of 10 or higher. Self-harm ideation was assessed on EPDS item 10: "The thought of harming myself has occurred to me" (yes, quite often; sometimes; hardly ever; never). Screen-positive women underwent evaluation with the Structured Clinical Interview for DSM-IV for Axis I primary and secondary diagnoses. RESULTS: Ten thousand mothers underwent screening, with positive findings in 1396 (14.0%); of these, 826 (59.2%) completed the home visits and 147 (10.5%) completed a telephone diagnostic interview. Screen-positive women were more likely to be younger, African American, publicly insured, single, and less well educated. More episodes began post partum (40.1%), followed by during pregnancy (33.4%) and before pregnancy (26.5%). In this population, 19.3% had self-harm ideation. All mothers with the highest intensity of self-harm ideation were identified with the EPDS score of 10 or higher. The most common primary diagnoses were unipolar depressive disorders (68.5%), and almost two-thirds had comorbid anxiety disorders. A striking 22.6% had bipolar disorders. CONCLUSIONS AND RELEVANCE: The most common diagnosis in screen-positive women was major depressive disorder with comorbid generalized anxiety disorder. Strategies to differentiate women with bipolar from unipolar disorders are needed. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00282776.

The effect of gastric bypass on the pharmacokinetics of serotonin reuptake inhibitors.

OBJECTIVE: Morbidly obese patients frequently present with mood and anxiety disorders, which are often treated with serotonin reuptake inhibitors (SRIs). Having observed that patients treated with SRIs frequently relapse after Roux-en-Y gastric bypass surgery, the authors sought to assess whether SRI bioavailability is reduced postoperatively. METHOD: Twelve gastric bypass candidates treated with an SRI for primary mood or anxiety disorders were studied prospectively. Timed blood samples for SRI plasma levels were drawn for pharmacokinetic studies before surgery and 1, 6, and 12 months afterward. Maximum concentration, time to maximum concentration, and area under the concentration/time curve (AUC) were determined. RESULTS: In eight of the 12 patients, AUC values 1 month after surgery dropped to an average of 54% (SD=18) of preoperative levels (range=36%-80%); in six of these patients, AUC values returned to baseline levels (or greater) by 6 months. Four patients had an exacerbation of depressive symptoms, which resolved by 12 months in three of them. Three of the four patients had a reduced AUC level at 1 month and either gained weight or failed to lose weight between 6 and 12 months. Normalization of the AUC was associated with improvement in symptom scores. CONCLUSIONS: Patients taking SRIs in this study were at risk for reduced drug bioavailability 1 month after Roux-en-Y gastric bypass. The authors recommend close psychiatric monitoring after surgery.