Longitudinal Outcomes of a Resident Academic Administrator, Clinician Educator Track.

OBJECTIVE: As clinician educator tracks continue to gain popularity in graduate medical education, this report aims to fill a gap in the literature by providing a 14-year update on professional outcomes of participants in a psychiatry residency academic administrator, clinician educator (AACE) track and to compare these outcomes to non-track participants. METHODS: An anonymous web-based survey querying professional achievements was distributed to all graduates of a psychiatry residency training program from 2009 to 2022. Outcomes of AACE track participants and non-track participants were compared. RESULTS: Of 228 alumni contacted, 61% responded (n = 140). Eighty-seven percent of track participants responded (n = 74) while 41% of non-track participants responded (n = 45). Of track participants, 63% practice in academic settings with 57% having held administrative leadership roles, 49% educational leadership roles, and 39% national or regional leadership roles. Track graduates were academically engaged with 70% reporting at least one publication, 89% at least one presentation, and 93% attending at least one national meeting. In comparison, 31% of non-track participants practice in academic settings with 44% having held administrative, 29% educational, and 20% national or regional leadership roles. Thirty-nine percent have at least one publication, 75% at least one presentation, and 90% attended at least one national meeting. When compared to non-track participants, track participants were significantly more likely to have an academic affiliation and a higher number of publications and were more likely to hold national or regional leadership roles. CONCLUSIONS: Track participants demonstrate longitudinal career success as clinician educators and academic administrators more so than non-track participants.

A lifespan perspective on depression in the postpartum period in a racially and socioeconomically diverse sample of young mothers.

BACKGROUND: Consistent evidence from retrospective reports and case registry studies indicates that a history of depression is a major risk factor for depression in the peripartum period. However, longitudinal studies with racially and socioeconomically diverse samples of young mothers are lacking, and little is known about developmental patterns of depression across the lifespan that can inform preventive interventions. METHODS: Young primiparous mothers (n = 399, 13-25 years, 81% Black) were recruited from a population-based prospective study that began in childhood. Women reported on depression symptoms for at least 3 years prior to their pregnancy, during pregnancy, and at 4 months postpartum. Linear regression models were used to estimate change in pre-pregnancy depression severity and to evaluate associations between patterns of lifetime history and postpartum depression symptoms. RESULTS: Results revealed high levels of continuity in depression from pregnancy to postpartum, and across multiple years pre-pregnancy to postpartum. Overall, depression severity leading up to pregnancy decreased over time, but patterns of worsening or improving symptoms were not associated with depression severity in the postpartum period. Instead, area under the pre-pregnancy trajectory curve, representing cumulative lifetime depression burden, was uniquely associated with postpartum depression after adjusting for prenatal depression severity. CONCLUSIONS: Depression in the postpartum period should be considered within a lifespan perspective of risk that accumulates before conception. Clinical screening and early interventions are needed in adolescence and young adulthood to prevent the onset and persistence of depressive symptoms that could have long-term implications for peripartum health.

Trauma-Informed Care for Obstetric and Gynecologic Settings.

PURPOSE: Trauma is common among those seeking Ob-Gyn care and may have pervasive impact on obstetrical and gynecological health, social functioning, and healthcare engagement. While guidelines exist on the detection and treatment of perinatal mood and anxiety disorders within Ob-Gyn care, the role of Ob-gyn clinicians in identifying and addressing patients' traumatic experiences and related symptoms is less clearly delineated. This manuscript provides an overview of trauma-related symptoms in the context of Ob-Gyn care and practical guidance of clinicians aiming to improve their detection and response to trauma in their clinical practice. DESCRIPTION: Posttraumatic stress disorder (PTSD) describes a psychiatric illness which develops as a response to a traumatic event. Women who have experienced trauma are also at increased risk for borderline personality disorder and other psychiatric comorbidities. Postpartum PTSD has particular relevance to obstetrical care. ASSESSMENT: Screening for trauma in Ob-Gyn care can provide an opportunity to address risk and offer targeted intervention. Several brief evidence-based screening tools are available. Individuals who screen positive require assessment of immediate safety and targeted referrals. Trauma informed care describes an approach to healthcare aimed to enhance physical and emotional safety for patients and clinicians. CONCLUSION: Given the prevalence and the potentially devastating and enduring impact of trauma and trauma-related symptoms, there is a critical need to address trauma within Ob-Gyn care. By recognizing the signs of trauma and initiating or referring to appropriate treatments, Ob-Gyn clinicians have a unique opportunity to better understand their patients and to improve their care.

Consideration of opioid agonist treatment in a pregnant adolescent: A case report and literature review.

Background: Opioid use greatly increases the risk of overdose death, as well as contracting human immunodeficiency virus (HIV) and hepatitis. Opioid agonist treatment is recommended for pregnant women who are dependent on opioids. However, there is a dearth of studies on the use of opioid agonist treatment in pregnant teenagers. Case: Ms. A, a 15 year-old G1PO in foster care, presented to our tertiary women's hospital requesting opioid agonist treatment for use of pill opioids. She reported nasal inhalation of 5-6 opioid tablets daily, with recent attempts to self-taper using nonprescribed buprenorphine since learning of her pregnancy. Last reported opioid use was >24 hours prior to admission. Urine drug testing was positive only for opioids (negative for buprenorphine and methadone). She did not exhibit significant withdrawal symptoms while hospitalized. The psychiatric treatment team recommended deferring opioid agonist treatment and pursuing outpatient substance use treatment. Unfortunately, Ms. A did not attend outpatient treatment and was lost to follow up. Discussion: Based upon our experience and review of the studies regarding opioid use disorder (OUD) and perinatal and adolescent opioid use, we recommend that pregnant adolescents with OUD be referred to opioid agonist treatment with buprenorphine or methadone. Studies specifically addressing opioid agonist treatment in pregnant teenagers are needed.

Self-Assessment of Teaching Skills Among Psychiatric Residents.

OBJECTIVE: Psychiatry residency programs have increasingly emphasized the role of resident-as-teacher; however, little is known about resident self-perceptions of teaching skills. This study reports on psychiatry residents' self-perceived skills in teaching medical students and compares cohort ratings with anonymous medical student evaluations of residents as teachers at our large academic residency program. METHODS: In May-June 2016, 84 residents in our program were surveyed using an anonymous, web-based survey, and this data was then compared to 3 years of aggregate data from anonymous student evaluations of resident teaching at our institution. RESULTS: Forty-seven (47) residents responded to the survey (56% response rate). Residents reported self-perceived deficits in several specific teaching competencies. Medical students consistently rated residents higher with respect to teaching skills than residents rated themselves, and these data were highly statistically significant. CONCLUSION: This study underscores the benefits of resident self-assessment in comparison to medical student evaluations of residents as teachers and this information can be used to inform training programs' resident-as-teacher curricula.

An Overview for the General Psychiatrist Evaluating Patients With Obstetric and Neonatal Complications and Perinatal Loss.

When neonatal and obstetrical complications occur, the identification and management of mood and anxiety disorders become complex with an ever-expanding array of psychiatric needs that include the management of grief- and trauma-related disorders. With high rates of maternal morbidity and mortality in the United States and laws in many states restricting reproductive health access, psychiatrists must be proficient in managing psychiatric sequelae in this context. High-risk groups for peripartum mood and anxiety disorders, posttraumatic stress disorder, and complicated grief include those with neonatal intensive care unit (NICU) stays and those who have experienced infertility and recurrent pregnancy loss. Groups who have been historically marginalized by the medical system (e.g., Black, Indigenous, people of color) and those from LGBTQ+ communities are at similarly high risk, and more interventions are needed to support these groups. Strategies emphasizing trauma-informed care, psychotherapeutic approaches, and using patient-centered language are recommended.

Pharmacologic Treatment of Sleep Disorders in Pregnancy.

Pregnancy is a unique physiologic state whose characteristics often predispose women to new-onset sleep disturbances or exacerbations of preexisting sleep disorders. Pregnancy-related factors that can disrupt sleep include heartburn, nocturnal oxytocin secretion, nocturia, and fetal movement. Sleep disorders in pregnancy include insomnia (primary and secondary), restless legs syndrome, and narcolepsy.

First-Episode Psychosis and the Role of the Psychiatric Consultant.

OBJECTIVE: Timely recognition and treatment of first-episode psychosis (FEP) is paramount. Studies suggest a significant relationship between longer duration of untreated psychosis and poorer functional outcomes. Limited data exist that characterize how treatment for FEP is initiated by consultation-liaison psychiatric services. We conducted a systematic review of FEP treatment by a consultation-liaison service at a large academic medical tertiary care. Approach to care was reviewed including recommendations for clinical assessment and management. METHODS: Psychiatric consultations performed at a tertiary academic center were reviewed to identify potential FEP cases during a 12-month period. Patients of ages 15-49 years, for whom the diagnostic assessment was concerning for possible FEP, were included. Demographic features and management were summarized. RESULTS: A total of 3365 new psychiatric consults were conducted during our study period. Of these, 28 were identified as having symptoms consistent with possible FEP (0.83% of total sample). However, only 12% were referred to coordinated specialty care for psychosis after discharge from an inpatient medical or psychiatric hospital. CONCLUSIONS: The results of our systemic chart review indicate that workup, management, and disposition recommendations for FEP patients seen by consultation-liaison services are variable, suggesting a need for a standardized, evidence-based approach in the medical setting.

Does the moderator matter? Identification of multiple moderators of the association between peripheral inflammatory markers and depression severity in a large racially diverse community cohort.

Depressive symptomology has been linked to low-grade peripheral inflammatory markers (PIMs), specifically C-reactive protein (CRP) and white blood cell count (WBC). However, such associations may be affected by multiple moderators (including race/ethnicity), though few well-powered and racially diverse studies have examined this. We examined 31 moderators of PIM-depression relationships in a large racially diverse cohort (n = 21,570). We also examined if associations between PIM and depression severity were dependent on clinical cutpoints for moderate depressive symptoms and elevated CRP. We found several positive moderators of PIM-depression relationships for both WBC and CRP: ongoing medication use (antidepressant, statin, or any prescription drug), presence of sleep concerns, and poor health status (ß's = 0.06-0.21, p's < 0.05). For both WBC and CRP, individuals of non-Hispanic White race/ethnicity were found to have stronger PIM-depression associations overall relative to minoritized groups (B's = 0.14 to 1.01, p's < 0.05). For CRP, stronger PIM-depression relationships existed for individuals with moderate (or greater) depression severity or elevated CRP (B's = 0.27 to 0.49, p's < 0.05). Thus, a wide range of moderators appears to affect PIM-depression associations. These results could help identify participants with strong coupling of PIM-depression severity, to guide future research and personalized treatments for depression and to indicate gaps in the applicability of widely referenced theoretical models among racial/ethnic minoritized groups.

Trauma Informed Care in the Obstetric Setting and Role of the Perinatal Psychiatrist: A Comprehensive Review of the Literature.

BACKGROUND: Trauma is highly prevalent, and women are twice as likely as men to develop posttraumatic stress disorder following a traumatic exposure. Consequently, many women entering the perinatal period have trauma histories. In the perinatal period, a trauma history can negatively impact treatment engagement and adversely affect the experience of pregnancy, postpartum, and parenting. A trauma-informed care approach can mitigate these effects. OBJECTIVE: This review aims to summarize literature that can aid psychiatrists in (1) identifying signs and symptoms of trauma in perinatal women, (2) integrating elements of trauma-informed care into perinatal mental health care, and (3) offering interventions that can minimize adverse outcomes for perinatal women and their children. METHODS: A PubMed search was conducted with keywords including trauma, pregnancy, perinatal, posttraumatic stress disorder, postpartum posttraumatic stress disorder, and trauma informed care. RESULTS: Perinatal care, given its somewhat invasive nature, has the potential to traumatize or cause retraumatization. Trauma-related disorders are common and can present or worsen in the perinatal period. Trauma can manifest in multiple forms in this population, including exacerbation of preexisting posttraumatic stress disorder, new onset acute stress disorder in the perinatal period, or postpartum posttraumatic stress disorder secondary to traumatic childbirth. Unaddressed trauma can adversely affect the experience of pregnancy, postpartum, and parenting. Psychiatrists caring for women in the perinatal period are in an ideal position to screen for trauma and offer appropriate intervention. A trauma-informed approach to obstetric care can help clinical teams respond to the unique trauma-related challenges that can arise during obstetric care. Trauma-informed care, with its emphasis on establishing a culture of safety, transparency, trustworthiness, collaboration, and mutuality, can empower health care providers and systems with powerful tools to respond to trauma and its myriad effects in a strengths-based manner. By applying a trauma-informed lens, psychiatrists can help their obstetric colleagues provide patient-centered compassionate care and treatment. CONCLUSIONS: Applying a trauma-informed approach to evaluation and treatment of perinatal populations could decrease the toll trauma has on affected women and their children.

A chicken and egg scenario in psychoneuroimmunology: Bidirectional mechanisms linking cytokines and depression.

Background: Cytokines are an important part of the immune system. Certain cytokines, such as interleukin-6 (IL-6) and tumor necrosis factor alpha (TNFα), have well-described associations with depression. Various mechanisms exist that may explain bidirectional effects of cytokines on depression and vice versa. No recent reviews to our knowledge have comprehensively characterized both these mechanisms and the interaction of these mechanisms using evidence from the molecular level to the clinical level. The goal of this review is to both evaluate the present knowledge base and identify knowledge gaps to help guide future research. Methods: We conducted an extensive bibliographic search across multiple databases, using both general (e.g. "cytokine") and topic-specific (e.g. "kynurenine") keywords. Results: We describe the most recent evidence outlining these mechanisms, including the role of the hypothalamic pituitary axis, the kynurenine pathway, and neural circuitry. For relevant topics, we outline the pathways by which cytokine activation may lead to depressive symptoms, and how depressive symptomology may lead to elevations in cytokines. We also identify key areas for future research, including the need for longitudinal clinical studies to examine causality in pertinent mechanisms and modulating factors in the cytokine-depression interaction. Limitations: Given the numerous potential mechanisms associating cytokines and depressions, this review paper solely focuses on the most commonly described mechanisms at a basic level. Conclusions: Bidirectional evidence exists for several mechanisms in the relationship between cytokines and depression. However, more work is required to further elucidate the role of these mechanisms in specific clinical populations.

Pharmacologic Treatment of Sleep Disorders in Pregnancy.

Pregnancy often predisposes women to new-onset sleep disturbances, as well as exacerbations of preexisting sleep disorders. The goals of treating perinatal sleep disorders include the promotion of restorative sleep and the benefits it brings to both mother and fetus. The prescribing of any sleep aid in pregnancy must include consideration of the risks and benefits for both the patient and her fetus. Although data on the perinatal use of sleep aids is limited, there may be effects on fetal development, timing and duration of delivery, and postnatal outcomes.