Contributions of common genetic variants to risk of schizophrenia among individuals of African and Latino ancestry.

Schizophrenia is a common, chronic and debilitating neuropsychiatric syndrome affecting tens of millions of individuals worldwide. While rare genetic variants play a role in the etiology of schizophrenia, most of the currently explained liability is within common variation, suggesting that variation predating the human diaspora out of Africa harbors a large fraction of the common variant attributable heritability. However, common variant association studies in schizophrenia have concentrated mainly on cohorts of European descent. We describe genome-wide association studies of 6152 cases and 3918 controls of admixed African ancestry, and of 1234 cases and 3090 controls of Latino ancestry, representing the largest such study in these populations to date. Combining results from the samples with African ancestry with summary statistics from the Psychiatric Genomics Consortium (PGC) study of schizophrenia yielded seven newly genome-wide significant loci, and we identified an additional eight loci by incorporating the results from samples with Latino ancestry. Leveraging population differences in patterns of linkage disequilibrium, we achieve improved fine-mapping resolution at 22 previously reported and 4 newly significant loci. Polygenic risk score profiling revealed improved prediction based on trans-ancestry meta-analysis results for admixed African (Nagelkerke's R2 = 0.032; liability R2 = 0.017; P < 10-52), Latino (Nagelkerke's R2 = 0.089; liability R2 = 0.021; P < 10-58), and European individuals (Nagelkerke's R2 = 0.089; liability R2 = 0.037; P < 10-113), further highlighting the advantages of incorporating data from diverse human populations.

The Psychology of Schizophrenia: Implications for Biological and Psychotherapeutic Treatments.

The focus on recent advances in the neurobiology of schizophrenia has pushed aside the psychological understanding of the person with schizophrenia for several decades. However, a useful functional psychology of schizophrenia (in distinction to a psychological approach to symptoms) remains clinically important for several reasons: it is a core part of the bio-psycho-social formulation; it helps us understand and connect with persons with schizophrenia; and it provides a framework by which to organize our treatment efforts (both psychotherapeutic and particularly biological), which can improve adherence and outcomes. A coherent psychological model (the deficit model) based on object relations theory best explains all the biological, psychological, clinical, and sociocultural factors relevant to the understanding and treatment of persons with schizophrenia. A better understanding of a coherent psychology of persons with schizophrenia and provision of psychotherapies improves both the biological and psychotherapeutic treatment of persons with schizophrenia.

Rapid Antigen Test Sensitivity for Asymptomatic COVID-19 Screening.

Introduction: Operating in-person instruction, residential living, and other activities at institutions of higher education (IHEs) in the context of the pandemic of severe acute respiratory syndrome-coronavirus 2 (SARS-Cov2) have posed a multitude of challenges. Identification of asymptomatic cases at IHEs is crucial, as a large reservoir of virus can potentially develop among students. Unfortunately, despite the advantages, rapid antigen tests (RATs) have variously been shown to perform poorly when used with asymptomatic individuals. Methods: In order to address the appropriateness of RAT use in screening asymptomatic populations like those at IHEs, we conducted a rapid review of published evaluations of RATs available in the United States, where sensitivity and specificity were reported specifically from asymptomatic populations. We extracted sensitivity and specificity for asymptomatic populations reported in each article, along with location and important notes. The data are presented narratively. Results: A total of 11 articles were included for evaluation and presentation, representing tests from four manufacturers. Sensitivity ranged from 35.8% to a high of about 71%, with caveats to the higher number about exposure. Both the low and high sensitivity rates were observed in Abbott BinaxNOW RATs. Due to heterogeneity and publishing differences, a meta-analysis was not feasible, but RAT tests in asymptomatic populations tended to identify roughly half of those identified as infected via reverse transcription-polymerase chain reaction. Specificity ranged from 97.8% to 100%. Conclusion: The results of this rapid review indicate serious issues in misidentifying asymptomatic individuals as COVID-19 negative, when in fact they are infected and carrying the SARS-Cov2 virus.

We Must Graduate Physicians, Not Doctors.

Today, medical schools graduate doctors, not physicians. Thousands of doctors who are U.S. citizens and graduates of U.S. and international medical schools will never become physicians because they do not obtain a residency position. Doctors need at least one year of residency to become a licensed physician. However, 4,099 applicants in 2018 and 4,170 in 2019 failed to get a position through the National Resident Matching Program Main Match; about 1,000 students get positions after the Main Match each year. The personal and societal cost is enormous: each year, approximately 3,000 nonphysician doctors cannot use 12,000 education years and three-quarters of a billion dollars they invested in medical education and cannot mitigate the shortfall of 112,000 physicians expected in 2030.To ameliorate this problem, medical schools could guarantee one year of residency. This is affordable: despite federally funded slots being capped, residency positions have increased for 17 consecutive years (20,602 in 2002 to 32,194 in 2019) because residents are cost-effective additions to the workforce. Alternatively, a 3-year curriculum plus required fourth-year primary care residency is another option. The salary during the residency year could equal other first-year residents', or there could be a token amount for this "internship." Both models decrease the cost of medical education; the second financially unburdens the hospital.Since the Flexner Report (when there was no formal postgraduate training), the end point of medical education has moved from readiness for independent medical practice (physician) to readiness for postgraduate training (doctor). To benefit individuals and society, medical education must take steps to ensure that all graduates are physicians, not just doctors.

Pathways to Independent Primary Care Clinical Practice: How Tall Is the Shortest Giant?

Patients can be treated by a physician, a nurse practitioner (NP), or a physician assistant (PA) despite marked differences in the education and training for these three professions. This natural experiment allows examination of a critical question: What is the minimum education and training required to practice primary care? In other words, how tall is the shortest giant? State licensing requirements, not educational bodies, legislate minimum training. The current minimum is 6 years, which includes 27.5 weeks of supervised clinical experience (SCE), for NPs. In comparison, PAs train for 6 years with 45 weeks of SCE, and physicians for at least 8 years with 110 weeks of SCE. Initial, flawed studies show equivalent patient outcomes among the professions. If rigorous follow-up studies confirm equivalence, the content and length of medical education for primary care physicians should be reconsidered. Unmatched medical school graduates, with 7 years of training and 65 weeks of SCE, more than the required minimum for NPs, deserve to practice independently. So do PAs. If equivalence is not confirmed, the minimum requirements for NPs and/or PAs should be raised, including considering a required residency (currently optional). Alternatively, the scope of practice for the three professions could be defined to reflect differences in training. There is an urgent need to set aside preconceived notions and turf battles, conduct rigorous independent studies, and generate meaningful data on practice patterns and patient outcomes. This should inform optimal training, scope of practice, and workforce development for each invaluable primary care clinical practitioner.

Comparing the side effect profile of the atypical antipsychotics.

Typical antipsychotics exert their effect by blocking post-synaptic dopaminergic receptors; blockade of the mesolimbic and mesocortical pathways are therapeutic and help reduce positive psychotic symptoms but blockade of the nigro-striatal pathway produces extrapyramidal side effects (EPSE). Post clozapine, the Food and Drug Administration (FDA) has approved the use of four newer atypical antipsychotics; risperidone, olanzapine, quetiapine and ziprasidone for the treatment of schizophrenia. Because of their dual serotonin and dopamine receptor blocking abilities, atypical antipsychotics have greater efficacy (especially for negative symptoms) and fewer EPSE when compared to the typical antipsychotics. Given the lack of studies directly comparing these agents, we used the Physician Desk Reference (PDR) to calculate the treatment emergent placebo adjusted side effects for these atypical antipsychotics. The results are then presented in an easy to read table. To the best of our knowledge, this is the first comparison study involving these four newer antipsychotic agents.

Evaluating competence in psychotherapy.

BACKGROUND: The Residency Review Committee (RRC) for Psychiatry has recently charged psychiatry training programs with developing methods to demonstrate competence of trainees in five areas of psychotherapy. Each program must decide what specific skills are essential for competence in each of the five listed psychotherapies. This requires determining whether those skills that are necessary are also sufficient for effective psychotherapy and whether additional specific skills are required for each one. METHOD: Two lists of general skills for psychotherapy are compared, one from the perspective of specific "schools" of psychotherapy and one from a more eclectic "integrative" approach. The issue of measuring competence is addressed by placing ratings of "competent" midway on a continuum from "novice" to "expert." Thirteen methods for measuring competence from the Accreditation Council for Graduate medical Education (ACGME) "tool-box" are described and reviewed with respect to applicability to psychotherapy. Examples of toolbox implementation are described based on a functioning psychotherapy evaluation program at the University of Missouri. RESULTS AND CONCLUSIONS: The authors found both theoretical as well as practical problems in measuring competence in psychotherapy. We propose that global rather than highly specific assessment methods may be more practical in these early stages of development, and we offer specific suggestions for assessment components that can currently be implemented.

Gabapentin's effect on agitation in severely and persistently mentally ill patients.

OBJECTIVE: To study the effects of adjunctive gabapentin on agitation in severely and persistently mentally ill (SPMI) inpatients. METHOD: Eleven chronic SPMI inpatients on stable psychotropic medication regimens were evaluated before and after the initiation of adjunctive gabapentin for six months. The following psychometric tests were used: Brief Psychiatric Rating Scale (BPRS), Corrigan Agitated Behavior Scale (CABS), and Clinical Global Impression (CGI)-Severity. Data collection was accomplished via retrospective chart review. An internal reliability check indicated that a chart review BPRS is significantly predictive of one performed face-to-face. RESULTS: Statistically significant reductions were found at six months for each assessment instrument (p < 0.05, two-tailed). BPRS scores were reduced from 40.6 to 33.2, CABS from 34.4 to 25.0, and CGI-Severity from 5.9 to 5.3. The bulk of the BPRS reduction was accounted for by several subscores exclusive of those assessing affective/anxious symptomatology. Adverse effects were minimal. Two patients were discharged 12 and 17 months after implementation of gabapentin. CONCLUSIONS: Adjunctive gabapentin appears to be associated with a reduction in agitation in chronically hospitalized SPMI patients. Controlled, prospective trials are needed before any definitive conclusion can be drawn regarding the role of gabapentin in the treatment of this group of patients.