The Burden of Leadership: a Survey of Burnout Experiences Among Psychiatry Program Directors.

OBJECTIVE: The objectives of this study were to examine the prevalence of burnout, specify contributors to and protective factors against burnout, and gather suggestions to improve well-being in psychiatry Program Directors. METHODS: A survey regarding burnout and wellness was distributed to psychiatric Program Directors through the email listserv of the American Association of Directors of Psychiatric Residency Training (AADPRT). RESULTS: The survey response rate was 273 responses out of 880 members surveyed (31%). The majority of respondents were current residency or fellowship Program Directors or Associate Program Directors or had another current educational role (93%, 227/245). Almost half of current Program Directors or Associate Program Directors reported feeling burned out almost daily or once a week (44%, 93/210). These Program Directors reported a desire to resign (77%), experienced discrimination within the past 5 years (66%), and struggled with finding meaning in their job (44%). The most frequently endorsed contributors to burnout were increasing administrative burden and insufficient support. CONCLUSIONS: The survey findings confirm that burnout characteristics are common among respondents, associated with a desire to resign and a struggle to find meaning in the highly demanding position of Program Director or Associate Program Director. Advocacy for resources, decreased administrative overload, and increased protected time would enhance well-being in Program Directors. Most striking was the frequency of discrimination reported and its relationship to burnout. Departments may benefit from a careful review of policies, procedures, and training to decrease hostile workplaces for women, international medical graduate, and under-represented in medicine Program Directors.

Using the Psychiatry Resident-In-Training Examination (PRITE) to Assess the Psychiatry Medical Knowledge Milestones in Psychiatry.

OBJECTIVE: The introduction of the Milestone Project underscored the need for objective assessments of resident progress across the competencies. Therefore, the authors examined the Psychiatry Resident-In-Training Examination (PRITE) utility for measuring improvements in medical knowledge (MK). METHODS: The authors compared the mean performance for each MK subcompetency by resident year for all residents taking the PRITE from 2015 to 2017 (18,175 examination administrations). In addition, they surveyed psychiatry residency program directors regarding how well they thought they teach these subcompetencies. RESULTS: Increases in MK subcompetencies by resident year were significant for Psychopathology (p < 0.003), Psychotherapy (p < 0.002), and Somatic Therapies (p < 0.000). Development, Clinical Neuroscience, and Practice of Psychiatry did not show statistically significant differences between postgraduate years. Eighty psychiatry program directors responded to the survey and felt optimistic about their ability to teach the Psychopathology, Psychotherapy, Somatic Therapies, and Practice of Psychiatry subcompetencies. CONCLUSIONS: The PRITE measured significant improvements in medical knowledge for several of the core subcompetencies. The program director's responses would suggest that the lack of statistically significant differences found for Development and Clinical Neuroscience reflects areas in need of curricular development. The disparity between PRITE performance and program director perception of the Practice of Psychiatry subcompetency may reflect difficulties in defining the scope of this subcompetency. Overall, this suggests that structured examinations help measure improvements in certain subcompetencies and may also help identify curricular needs. However, there may be potential problems with the definition of some subcompetencies.

A Randomized, Phase 3, Double-Blind, Crossover Comparison of Multilayer, Extended-Release Methylphenidate (PRC-063), and Lisdexamfetamine in the Driving Performance of Young Adults With ADHD.

OBJECTIVE: To compare PRC-063 (multilayer-release methylphenidate) and lisdexamfetamine dimesylate (LDX) on the driving performance of young adults with attention deficit hyperactivity disorder (ADHD) in a randomized, double-blind, crossover study. METHOD: Following up to 21 days of each treatment in each treatment course (PRC-063/LDX or LDX/PRC-063), subjects completed a 15-hour driving simulator laboratory assessment. The primary outcome measure was the Tactical Driving Quotient (TDQ) and the Clinical Global Impressions-Improvement (CGI-I) scale was a secondary outcome measure. RESULTS: Forty-four subjects completed the study. PRC-063 and LDX had equivalent effects on driving performance through a 15-hour time period (least square mean difference -0.3 [standard error 1.08], 95% confidence interval [-2.4, 1.8], p = .793). Consistent improvement in CGI-I was observed. The incidence of treatment-emergent adverse events was similar for each treatment sequence. CONCLUSIONS: PRC-063 and LDX had comparable effects on driving performance, from 1 through 15 hours, the last time point measured.

Adult attention-deficit/hyperactivity disorder and driving: why and how to manage it.

Driving is a complex task that can be a significant challenge for individuals with attention-deficit/hyperactivity disorder (ADHD). A slight lapse in attention or inhibition while driving (not uncommon in individuals with ADHD) can result in hazardous consequences for these individuals and their families. This is also an interesting clinical scenario for the treating physician, who is always trying to optimize the various treatment options for the patient. Despite such potentially perilous consequences for society, this subject only recently has received researchers' attention. This review paper highlights the psychological differences between drivers with and without ADHD and examines differences between these groups in various driving simulation models. Research updates involving pharmacologic and nonpharmacologic interventions are discussed at length. Although the long-term effects of such interventions may not be clearly defined, there is enough evidence to suggest the public health significance of such interventions for optimally managing adult symptoms of ADHD.

Ethical and Clinical Considerations During the Coronavirus Era.

The practice of child and adolescent psychiatry is evolving during an unprecedented global health catastrophe, the coronavirus disease 2019 (COVID-19) pandemic. As child and adolescent psychiatrists grapple with COVID-19's enormous medical, educational, social, and economic toll, a mental health crisis is co-occurring. Pre-existing disparities are recognized as contributors to the disproportionate impact of the COVID-19 pandemic on racial and ethnic minorities.1 The magnitude of COVID-19's effects on child and family mental health has yet to be fully revealed. child and adolescent psychiatrists are in a unique position to address this mental health crisis. Child and adolescent psychiatrists must stay up-to-date regarding federal, state, local, and institutional mandates, regulations, and policies informed by the Centers for Disease Control and Prevention2 and other public health institutions, while also navigating the ethical dilemmas unique to child and adolescent psychiatry during the coronavirus era.

Neuropeptides: relevance in treatment of depression and anxiety disorders.

The etiology and pathophysiology of both depression and anxiety remain unclear, but involve dysfunctional monoaminergic neurotransmission and function. The currently available antidepressant medications that work through optimizing the monoaminergic system are often limited by their lack of efficacy or their adverse effects. There is increasing evidence that some neuropeptides, including substance P, corticotropin-releasing factor, neuropeptide Y, vasopressin and galanin, may have relevance in both depression and anxiety. Integration of anatomical, physiological and clinical evidence suggests that modulation of monoaminergic transmission is the most likely mechanism by which neuropeptides may work in these disorders. These neuropeptides and their receptors may serve not only as potential therapeutic targets for treatment of depression and anxiety, but may also help enhance our understanding of the psychopathology of these two major psychiatric disorders.

Assessing the efficacy of treatments for ADHD : overview of methodological issues.

Attention-deficit hyperactivity disorder (ADHD) is a common and impairing psychiatric condition that affects significant numbers of children, adolescents and adults. Clinicians in a variety of practice settings (hospital, outpatient, residential, research) strive to diagnose, treat and monitor ADHD in an efficient and evidence-based manner. Tools that facilitate the gathering and interpretation of information from a variety of sources can effectively augment a diagnostic assessment, and can also be useful for longitudinal monitoring. Multiple assessment tools are available, with varying degrees of psychometric validity, clinical utility and overall feasibility (time and cost). This review provides an overview of several available ADHD rating scales and continuous performance tests, and offers a discussion of potential strengths and weaknesses of the instruments. While these tools do not in and of themselves make a diagnosis of ADHD, they can certainly assist in the diagnostic assessment, be crucial in assessing the efficacy of medications in clinical trials, and be a useful adjunct in the clinical management of ADHD.

Behavioral manifestations of sturge-weber syndrome: a case report.

Sturge-Weber syndrome is a neurocutaneous syndrome that manifests with vascular malformations involving the brain, eye, and skin. We report the case of an elderly patient suffering from Sturge-Weber syndrome who presented with episodic "angry" slapping symptoms to a psychiatric facility. A detailed history, physical and mental-state examination, and elaborate neuropsychological, neuroimaging, and laboratory assessment were undertaken. Clinically, the "angry" slapping episodes were diagnosed as complex partial seizures that improved in frequency with an increase in the dose of the antiepileptic medication. We also have attempted to identify the pathophysiology of such behavioral episodes in Sturge-Weber syndrome. This case report underlines the need for detailed laboratory and neuroimaging work-up in the elderly presenting with atypical symptoms. It also emphasizes the need for identification of and differentiation between similar atypical presentations and appropriate management of resources by the medical staff.

Teaching Ethics in Child and Adolescent Psychiatry: Vignette-Based Curriculum.

INTRODUCTION: Ethics is an integral component of child and adolescent psychiatry. While ethics can seem abstract or philosophical, its tenets are fundamental to the practice of medicine. Understanding relevant ethical principles shapes how practitioners make decisions in all activities, including clinical, administrative, research, and scholarly. METHODS: Using the American Academy of Child and Adolescent Psychiatry (AACAP) Code of Ethics as the framework, these vignettes serve as stimulus material to help teach the ethical principles relevant to child and adolescent psychiatry practice. Each vignette briefly describes a clinical situation in practice, followed by questions and possible appropriate responses. The teacher's guide includes a discussion of the relevant ethical principles and perspectives on how to think about the issues involved. A supplementary overview of ethical issues in child and adolescent psychiatry and a list of resources are also provided. RESULTS: We and other child and adolescent psychiatrists have used this curriculum at professional organizational meetings, in residency programs, and in teaching medical students with positive learner responses. DISCUSSION: This curriculum was developed by members of the AACAP Ethics Committee with input from the entire committee in an effort to produce material that was easy to use and provided valuable content about an essential aspect of practice that is relevant to all practitioners at all levels. While designed for child and adolescent psychiatrists, the content is relevant to all physicians working with children, adolescents, and families.

Aripiprazole for the treatment of Tourette's disorder.

OBJECTIVE: Tourette's disorder is a neuropsychiatric syndrome that manifests with motor and vocal tics, including coprolalia. This article presents a report of successful treatment of these tics with aripiprazole in 2 consecutive patients with Tourette's disorder. METHOD: After an informed consent was obtained from the subjects, approval for this retrospective case series was sought from the Institutional Review Board. A detailed history was obtained and physical and mental state examination was performed for each patient. Tic severity was assessed using the Yale Global Tic Severity Scale. Aripiprazole was started at a low dose (5 mg/day) and titrated. The severity of tics was monitored during follow-up. RESULTS: The 2 individuals presented in these case reports tolerated aripiprazole well and showed a clinically significant decrease in tic frequency and severity. CONCLUSIONS: Aripiprazole, a newer atypical antipsychotic with a unique pharmacodynamic profile, appears to be efficacious in treatment of tics in Tourette's disorder, thus impressing upon the need for placebo-controlled trials in the management of this neuropsychiatric syndrome.

A primary care perspective of posttraumatic stress disorder for the Department of Veterans Affairs.

Posttraumatic stress disorder (PTSD) is a major mental disorder associated with significant morbidity, psychosocial impairment, and disability. The diagnosis of PTSD can be missed in a primary care setting, as patients frequently present with somatic complaints or depression and are often reluctant to discuss their traumatic experiences. As recent studies of veterans returning from the Gulf War and the Iraqi War suggest high rates of PTSD, the U.S. Department of Veterans Affairs (VA) Hospitals are gearing up to face this challenge. It is important to screen these veterans for symptoms of PTSD and make an appropriate referral if required. In this article, we attempt to review PTSD with a special focus on the VA population. In addition to discussing the epidemiology, diagnosis, and treatment options for PTSD, we also suggest screening questions for both combat-related and military sexual trauma-related PTSD.

Update on optimal use of lisdexamfetamine in the treatment of ADHD.

Lisdexamfetamine (LDX) has been a recent addition to the treatment armamentarium for Attention Deficit Hyperactivity Disorder (ADHD). It is unique among stimulants as it is a prodrug, and has been found to be safe and well-tolerated medication in children older than 6 years, adolescents and adults. It has a smooth onset of action, exerts its action up to 13 hours and may have less rebound symptoms. LDX has proven to be effective in the treatment of ADHD in placebo controlled trials, and improved performance in simulated academic and work environments have been noticed. Both stimulant-naïve and stimulant-exposed patients with ADHD appear to benefit from LDX. It has also shown some promise in improving emotional expression and executive function of patients with ADHD. Adverse effects such as decrease in sleep, loss of appetite and others have been reported with LDX use, just as with other stimulant formulations. Since most such studies exclude subjects with preexisting cardiac morbidity, prescribing precautions should be taken with LDX in such subjects, as with any other stimulant. Study subjects on LDX have been reported to have low scores on drug likability scales, even with intravenous use; as a result, LDX may have somewhat less potential for abuse and diversion. There is a need for future studies comparing other long acting stimulants with LDX in ADHD; in fact clinical trials comparing LDX with OROS (osmotic controlled-release oral delivery system) methylphenidate are currently underway. Furthermore, the utility of this medication in other psychiatric disorders and beyond ADHD is being investigated.

The Bhagavad Gita and contemporary psychotherapies.

The Bhagavad Gita is based on a discourse between Lord Krishna and Arjuna at the inception of the Kurukshetra war and elucidates many psychotherapeutic principles. In this article, we discuss some of the parallels between the Gita and contemporary psychotherapies. We initially discuss similarities between psychodynamic theories of drives and psychic structures, and the concept of three gunas. Arjuna under duress exhibits elements of distorted thinking. Lord Krishna helps remedy this through a process akin to Cognitive Behavioral Therapy (CBT). We ascertain the analogies between the principles of Gita and CBT, grief emancipation, role transition, self-esteem, and motivation enhancement, as well as interpersonal and supportive psychotherapies. We advocate the pragmatic application of age old wisdom of the Gita to enhance the efficacy of psychotherapeutic interventions for patients from Indian subcontinent and to add value to the art of western psychotherapies.

Diagnosis of depression in adolescents following traumatic fracture: a retrospective analysis.

OBJECTIVE: To assess how frequently adolescents are clinically diagnosed with depression following hospitalization for traumatic fracture, with the assumption that a retrospective approach would yield lower rates of depression compared to those reported previously in prospective studies. We hypothesized that depression would be less common among adolescents whose injuries were primarily limited to fractures of the appendicular skeleton, vertebral column, and/or thoracic cage compared to those sustaining concomitant spinal cord and/or brain injuries and those suffering from facial/skull fractures. METHOD: A patient population of 1,121 adolescents, aged 12 to 19 years, who were hospitalized overnight at the University of Virginia (UVA) Health System, Charlottesville, for fractures between 2000 and 2009, was generated using the health system's Clinical Data Repository. The number of these adolescents who received a new diagnosis of depression (per ICD-9 codes) at the UVA Health System within the first year following their injury was determined. RESULTS: By the end of the first year, 37 of 913 adolescents (4.1%) who had at least 1 follow-up visit after their fracture were diagnosed with depression. When patients with a concomitant spinal cord injury and those with a facial/skull fracture with or without an associated brain injury were excluded, this percentage dropped to 3.2% and 1.1%, respectively. CONCLUSIONS: The results support our initial hypothesis that the percentage of adolescents diagnosed with depression following a traumatic fracture determined retrospectively would be lower than the percentages previously reported in related prospective studies. This finding adds to the growing concern that depression in youth is underdiagnosed, even among youth who have contact with health care providers. When compared to our own retrospectively determined data, the much higher rates of depression reported in several prospective studies indicate that more proactive, routine implementation of depression screening tools in the postinjury period is likely to improve identification of at-risk youth.