Patient and Provider Satisfaction with Asynchronous Versus Synchronous Telepsychiatry in Primary Care: A Secondary Mixed-Methods Analysis of a Randomized Controlled Trial.

Background: Asynchronous telepsychiatry (ATP) consultations are a novel form of psychiatric consultation. Studies comparing patient and provider satisfaction for ATP with that for synchronous telepsychiatry (STP) do not exist. Methods: This mixed-methods study is a secondary analysis of patients' and primary care providers' (PCPs) satisfaction from a randomized clinical trial of ATP compared with STP. Patients and their PCPs completed satisfaction surveys, and provided unstructured feedback about their experiences with either ATP or STP. Differences in patient satisfaction were assessed using mixed-effects logistic regression models, and the qualitative data were analyzed using thematic analysis with an inductive coding framework. Results: Patient satisfaction overall was high with 84% and 97% of respondents at 6 months reported being somewhat or completely satisfied with ATP and STP, respectively. Patients in the STP group were more likely to report being completely satisfied, to recommend the program to a friend, and to report being comfortable with their care compared with ATP (all p < 0.05). However, there was no difference between the patients in ATP and STP in perceived change in clinical outcomes (p = 0.51). The PCP quantitative data were small, and thus only summarized descriptively. Conclusions: Patients expressed their overall satisfaction with both STP and ATP. Patients in ATP reported more concerns about the process, likely because feedback after ATP was slower than that after STP consultations. PCPs had no apparent preference for STP or ATP, and reported implementing the psychiatrists' recommendations for both groups when such recommendations were made, which supports our previous findings. Trial Registration: ClinicalTrials.gov NCT02084979; https://clinicaltrials.gov/ct2/show/NCT02084979.

Modeling the social determinants of resilience in health professions students: impact on psychological adjustment.

Stressors inherent to training and stemming from the learning environment are associated with high rates of burnout, depression, and mental health problems in health professions students (HPS). There is evidence that disadvantaged or stigmatized groups are particularly affected. These problems not only impact students after graduation but may also have detrimental effects on patient outcomes. Resilience, conceptualized as the process of adapting well in the face of adversity, has inspired an increasing number of interventions aimed at addressing those problems in HPS. These interventions have mostly targeted individual students and their psychological traits while ignoring social and structural factors that may enhance or undermine individual resilience. To address this gap in the literature, the authors reviewed the evidence for psychosocial determinants of resilience and proposed a model inspired by the social determinants of health literature and the "upstream-downstream" metaphor. In this theoretical paper, the authors propose that upstream determinants such adverse childhood experiences and socioeconomic and sociodemographic markers of disadvantage have a direct effect on psychological adjustment and an indirect effect mediated by resilience. Additionally, the authors propose that the institutional downstream drivers of learning environment, social support, and sense of belonging moderate the direct and indirect effects of the upstream determinants on psychological adjustment. Future research should test these hypotheses and gather evidence that may guide the development of interventions. The authors present their model as part of a comprehensive response to recent calls to action to address diversity, equity and inclusion in health professions education.

Bringing Needed Change to Medical Student Well-Being: A Call to Expand Accreditation Requirements.

Issue: Noting high rates of burnout, depression, and suicidality among medical students, academic medical communities are trying to identify preventive and curricular measures that protect and promote student well-being. To date, the effectiveness of these efforts is unclear. In addition, evidence increasingly suggests that the major drivers of distress appear to be factors within the social, learning, and work environments. Specific to medical schools in the United States, neither the Liaison Committee on Medical Education nor the Commission on Osteopathic College Accreditation include accreditation standards regarding well-being curricula and, as such, these curricula are not well-integrated into students' medical school experience. Current accreditation standards also do not specifically require institutions to assess or address systemic factors of the learning environment that negatively affect student well-being. Evidence: This paper proposes expanding current Liaison Committee on Medical Education and Commission on Osteopathic College Accreditation standards on professionalism to incorporate well-being as a core component of professional identity formation by requiring individual and institutional-level actions. Proposed changes to accreditation standards include (1) institutional assessment of the impact of the learning environment on student well-being; (2) continuous quality improvement efforts to address structural factors associated with student well-being and modification of practices that impair student well-being; and (3) integrated curriculum with related assessment to educate students on empirically-supported strategies for well-being. Implications: Refining undergraduate medical education accreditation standards in the United States to include language specific to student well-being will facilitate long overdue changes to the learning environment. In the end, the goal is not just to improve medical student well-being, but to provide a workforce better equipped for a sustainable and meaningful career.

Clinical Outcomes of Asynchronous Versus Synchronous Telepsychiatry in Primary Care: Randomized Controlled Trial.

BACKGROUND: Asynchronous telepsychiatry (ATP; delayed-time) consultations are a novel form of psychiatric consultation in primary care settings. Longitudinal studies comparing clinical outcomes for ATP with synchronous telepsychiatry (STP) are lacking. OBJECTIVE: This study aims to determine the effectiveness of ATP in improving clinical outcomes in English- and Spanish-speaking primary care patients compared with STP, the telepsychiatry usual care method. METHODS: Overall, 36 primary care physicians from 3 primary care clinics referred a heterogeneous sample of 401 treatment-seeking adult patients with nonurgent psychiatric disorders. A total of 184 (94 ATP and 90 STP) English- and Spanish-speaking participants (36/184, 19.6% Hispanic) were enrolled and randomized, and 160 (80 ATP and 80 STP) of them completed baseline evaluations. Patients were treated by their primary care physicians using a collaborative care model in consultation with the University of California Davis Health telepsychiatrists, who consulted with patients every 6 months for up to 2 years using ATP or STP. Primary outcomes (the clinician-rated Clinical Global Impressions [CGI] scale and the Global Assessment of Functioning [GAF]) and secondary outcomes (patients' self-reported physical and mental health and depression) outcomes were assessed every 6 months. RESULTS: For clinician-rated primary outcomes, ATP did not promote greater improvement than STP at 6-month follow-up (ATP vs STP, adjusted difference in follow-up at 6 months vs baseline differences for CGI: 0.2, 95% CI -0.2 to 0.6; P=.28; and GAF: -0.6, 95% CI -3.1 to 1.9; P=.66) or 12-month follow-up (ATP vs STP, adjusted difference in follow-up at 12 months vs baseline differences for CGI: 0.4, 95% CI -0.04 to 0.8; P=.07; and GAF: -0.5, 95% CI -3.3 to 2.2; P=.70), but patients in both arms had statistically and clinically significant improvements in both outcomes. There were no significant differences in improvement from baseline between ATP and STP on any patient self-reported ratings at any follow-up (all P values were between .17 and .96). Dropout rates were higher than predicted but similar between the 2 arms. Of those with baseline visits, 46.8% (75/160) did not have a follow-up at 1 year, and 72.7% (107/147) did not have a follow-up at 2 years. No serious adverse events were associated with the intervention. CONCLUSIONS: This is the first longitudinal study to demonstrate that ATP can improve clinical outcomes in English- and Spanish-speaking primary care patients. Although we did not find evidence that ATP is superior to STP in improving clinical outcomes, it is potentially a key part of stepped mental health interventions available in primary care. ATP presents a possible solution to the workforce shortage of psychiatrists and a strategy for improving existing systems of care. TRIAL REGISTRATION: ClinicalTrials.gov NCT02084979; https://clinicaltrials.gov/ct2/show/NCT02084979.

Asynchronous Telepsychiatry Interviewer Training Recommendations: A Model for Interdisciplinary, Integrated Behavioral Health Care.

Objective: Asynchronous telepsychiatry (ATP) is an integrative model of behavioral health service delivery that is applicable in a variety of settings and populations, particularly consultation in primary care. This article outlines the development of a training model for ATP clinician skills. Methods: Clinical and procedural training for ATP clinicians (n = 5) was provided by master's-level, clinical mental health providers developed by three experienced telepsychiatrists (P.Y. D.H., and J.S) and supervised by a tele-psychiatrist (PY, GX, DL) through seminar, case supervision, and case discussions. A training manual and one-on-one sessions were employed for initial training. Unstructured expert discussion and feedback sessions were conducted in the training phase of the study in year 1 and annually thereafter over the remaining 4 years of the study. The notes gathered during those sessions were synthesized into themes to gain a summary of the study telepsychiatrist training recommendations for ATP interviewers. Results: Expert feedback and discussion revealed three overarching themes of recommended skill sets for ATP interviewers: (1) comprehensive skills in brief psychiatric interviewing, (2) adequate knowledge base of behavioral health conditions and therapeutic techniques, and (3) clinical documentation, integrated care/consultation practices, and e-competency skill sets. The model of training and skill requirements from expert feedback sessions included these three skill sets. Technology training recommendations were also identified and included: (1) awareness of privacy/confidentiality for electronic data gathering, storage, management, and sharing; (2) technology troubleshooting; and (3) video filming/retrieval. Conclusions: We describe and provide a suggested training model for the use of ATP integrated behavioral health. The training needs for ATP clinicians were assessed on a limited convenience sample of experts and clinicians, and more rigorous studies of training for ATP and other technology-focused, behavioral health services are needed. Clinical Trials number: NCT03538860.

The Suicide Prevention, Depression Awareness, and Clinical Engagement Program for Faculty and Residents at the University of California, Davis Health.

OBJECTIVE: The objective of the study is to present results of a depression and suicide screening and treatment referral program for physicians at an academic medical center. METHODS: An anonymous web-based screening questionnaire was sent to all physicians at a large academic center. Responses were classified as indicating either high, moderate, or low risk for depression and suicide. Physicians at high and moderate risk were contacted by a counselor through a messaging system. The counselor's message contained information on risk level and an invitation to meet in person. High-risk respondents who did not reply to the message or declined to meet received mental health resources. Respondents who met with the counselor were offered individualized treatment referrals and to participate in a 1-year follow-up of self-reports every 3 months. RESULTS: The questionnaire was sent to approximately 1800 residents, fellows, and faculty from February 2013 through March 2019. A total of 639 questionnaires were received, 100 were excluded for various reasons, and 539 were used to conduct analyses (14.4% response rate). The majority of respondents were classified at moderate (333 [62%]) or high (193 [36%]) risk for depression or suicide. Eighty-three respondents were referred for mental health care, and 14 provided data for the follow-up study. CONCLUSIONS: Results of screening physicians for depression and suicide at one academic medical center highlight the challenges of engaging most of them in this activity and the satisfaction of the minority who successfully engaged in a treatment referral program.

Exploring the Relationships Between Resilience and News Monitoring with COVID Distress in Health Profession Students.

OBJECTIVE: Alarming rates of anxiety and burnout in pre-clinical health profession trainees are now challenged by additional COVID-19 stressors. This study explored COVID-related stressors among first-year medical, physician assistant, nurse practitioner, and veterinary medical students. The authors examined associations between resilience, news monitoring, and COVID stress. METHODS: Students completed an online questionnaire that included the Brief Resilience Scale at their matriculation in August 2019. Survey results were linked to demographic information collected by all schools. A follow-up survey in May 2020 included original questions on COVID-19 stressors and news monitoring. Statistical analyses included descriptive statistics and multivariable linear regression models. RESULTS: Across schools, 74% (266/360) provided consent for the 2019 survey, and 76% (201/264) responded to COVID-19 questions in the follow-up 2020 survey. Students were "extremely" or "very" concerned about family members getting infected (n = 71, 76% School of Medicine (SOM); n = 31, 76% School of Nursing (SON); n = 50, 75% School of Veterinary Medicine (SVM)) and curriculum schedule changes (n = 72, 78%, SOM; n = 28, 68% SON; n = 52, 79% SVM). Greater frequency of COVID news monitoring was associated with greater COVID-related stress (p = 0.02). Higher resilience at matriculation was associated with lower COVID-related stress ten months later (p < 0.001). CONCLUSIONS: Amid COVID-19 uncertainty, health science schools should address the immense student stress regarding curriculum disruptions. The results of this study underscore the powerful role of resilience in protecting against stress not only during the known academic rigor of health professions training but also during unprecedented crises.

Adverse Childhood Experiences in Medical Students: Implications for Wellness.

OBJECTIVE: The primary purpose of the study was to assess the prevalence of adverse childhood experiences (ACEs) in a cohort of third-year medical students and characterize their childhood protective factors. METHODS: The authors developed a web-based anonymous survey distributed to all third-year medical students in one school (N = 98). The survey included the 10-item ACE Study questionnaire, a list of childhood protective factors (CPF) and questions to assess students' perception of the impact of ACEs on their physical and mental health. The medical school's IRB approved the student survey as an exempt study. The authors computed descriptive and comparative statistical analyses. RESULTS: Eighty-six of 98 students responded (88% response rate). Forty-four students (51%) reported at least one ACE exposure and 10 (12%) reported ≥ 4 exposures. The latter were all female. The average difference in the ACE score between male and female medical students was - 1.1 (independent t test with unequal variances t(57.7) = - 2.82, P = .007). Students with an ACE score of ≥ 4 were significantly more likely to report a moderate or significant effect on their mental health, compared with students with scores ≤ 3 (chi-square test, P = < .0001). Most students reported high levels of CPF (median score = 13 of a maximum score = 14). ACEs and CPF were inversely associated (Pearson correlation = - 0.32, P = .003). CONCLUSIONS: A sizeable minority of medical students reported exposure to multiple ACEs. If replicated, findings suggest a significant vulnerability of these medical students to health risk behaviors and physical and mental health problems during training and future medical practice.

Asynchronous Telepsychiatry: A Component of Stepped Integrated Care.

OBJECTIVE: Integrated behavioral healthcare models typically involve a range of consultation options for mental healthcare. Asynchronous telepsychiatry (ATP) consults may be an additional potential choice, so we are conducting a 5-year clinical trial comparing ATP with synchronous telepsychiatry (STP) consultations. METHODS: Patients referred by primary care providers are randomly assigned to one of the two treatment groups, ATP or STP. Clinical outcome, satisfaction, and economic data are being collected from patients for 2 years at 6-month intervals. RESULTS: Baseline characteristics for the first 158 patients and case examples of ATP are presented. CONCLUSION: Implementing ATP in existing integrated behavioral healthcare models could make mental healthcare more efficient.

Family-centered depression treatment for older men in primary care: a qualitative study of stakeholder perspectives.

BACKGROUND: Family members often play important roles in the lives of depressed older men and frequently attend primary care visits with their loved ones, yet surprisingly little is known about how to most effectively engage and include family members in depression treatment. However, including family in depression treatment may be difficult due to several factors, such as depression stigma and family conflicts. The objective of this study was to describe challenges in engaging family members in older men's depression treatment and potential strategies to overcome those challenges. METHODS: A cross-sectional, qualitative descriptive interview study was conducted in a safety-net, Federally Qualified Health Center in California's Central Valley. A total of 37 stakeholders were recruited, including 15 depressed older (i.e. age ≥ 60) men, 12 family members, and 10 clinic staff. Depressed men were identified through mail outreach, waiting room screening, and referral. Depressed men identified family members who were later approached to participate. We also recruited a purposeful sample of clinic staff. Interviews explored stakeholder perspectives on family involvement in men's depression treatment as part of a primary care intervention. Interviews were conducted using a semi-structured interview guide, tape-recorded, transcribed verbatim, and translated if the interview was conducted in Spanish. RESULTS: Four themes were identified representing core challenges: engaging men at the right time; preserving men's sense of autonomy; managing privacy concerns; and navigating family tensions. Stakeholders also provided practical suggestions and advice about how each of these challenges might be addressed. CONCLUSIONS: While engaging family is a promising approach to strengthen depression care for older men in primary care settings, several potential challenges exist. Family- centered depression intervention development and clinical practice need to anticipate these challenges and to develop approaches and guidelines to address them.

The Suicide Prevention, Depression Awareness, and Clinical Engagement Program for Faculty and Residents at the University of California, Davis Health System.

OBJECTIVE: The authors replicated a program developed by UC San Diego, identified medical staff at risk for depression and suicide using a confidential online survey, and studied aspects of that program for 1 year. METHODS: The authors used a 35-item, online assessment of stress and depression depression developed and licensed by the American Foundation for Suicide Prevention that aims to identify and suicide risk and facilitate access to mental health services. RESULTS: During 2013/2014, all 1864 UC Davis residents/fellows and faculty physicians received an invitation to take the survey and 158 responded (8% response rate). Most respondents were classified at either moderate (86 [59%]) or high risk for depression or suicide (54 [37%]). Seventeen individuals (11%) were referred for further evaluation or mental health treatment. Ten respondents consented to participate in the follow-up portion of the program. Five of the six who completed follow-up surveys reported symptom improvement and indicated the program should continue. CONCLUSIONS: This program has led to continued funding and a plan to repeat the Wellness Survey annually. Medical staff will be regularly reminded of its existence through educational interventions, as the institutional and professional culture gradually changes to promptly recognize and seek help for physicians' psychological distress.

Roadmap for Trauma-Informed Medical Education: Introducing an Essential Competency Set.

Research has established that trauma is nearly universal and a root cause of numerous health and social problems, including 6 of the 10 leading causes of death, with devastating consequences across the life course. Scientific evidence now recognizes the complex injurious nature of structural and historical trauma (i.e., racism, discrimination, sexism, poverty, and community violence). Meanwhile, many physicians and trainees grapple with their own trauma histories and face direct and secondary traumatization on the job. These findings substantiate the profound impact of trauma on the brain and body and why trauma training is critical to the education and practice of physicians. However, a critical lag remains in translating essential research insights into clinical teaching and care. Recognizing this gap, the National Collaborative on Trauma-Informed Health Care Education and Research (TIHCER) formed a task force charged with developing and validating a summary of core trauma-related knowledge and skills for physicians. In 2022, TIHCER released the first-ever validated set of trauma-informed care competencies for undergraduate medical education. The task force focused on undergraduate medical education so that all physicians would be taught these foundational concepts and skills from the outset of training, recognizing that faculty development is needed to achieve this goal. In this Scholarly Perspective, the authors offer a roadmap for implementation of trauma-informed care competencies starting with medical school leadership, a faculty-student advisory committee, and sample resources. Medical schools can use the trauma-informed care competencies as a scaffold to customize integration of curricular content (what is taught) and efforts to transform the learning and clinical environments (how it is taught). Using the lens of trauma will ground undergraduate medical training in the latest science about the pathophysiology of disease and provide a framework to address many of our greatest challenges, including health disparities and professional burnout.

A roadmap for observership programs in psychiatry for international medical graduates.

OBJECTIVE: International medical graduates (IMGs) constitute a significant proportion of the psychiatric workforce in the United States. Observership programs serve an important role in preparing IMGs for U.S. residency positions; yet there are limited resources with information available on establishing these observerships, and none specific to psychiatry. In this article, authors present a roadmap for observership programs in psychiatry for IMGs. METHOD: This article draws on the experience of the IMG committee of the Group for Advancement of Psychiatry in establishing observership programs. RESULTS: Authors highlight the benefits of observership programs to IMGs, psychiatry departments, and the U.S. medical system as a whole. The different components of an observership program are presented, along with core competencies that need to be acquired. The authors discuss challenges that observership programs may encounter as well as recommendations for overcoming them. CONCLUSION: Observership programs provide a unique opportunity to integrate IMGs into the U.S. medical system. This article provides a framework for establishing such programs in a way that will optimize their benefits and avoid potential pitfalls.

Do psychiatry residents identify as psychotherapists? A multisite survey.

BACKGROUND: Psychiatric training was once synonymous with learning psychotherapy, but current psychiatric trainees face many options for integrating psychopharmacology and psychotherapy into their future practices, including providing primarily medication-focused visits. We examined psychiatry residents' attitudes towards learning psychotherapy, practicing psychotherapy in the future, and overall identification as psychotherapists. METHODS: We surveyed residents from 15 US residency programs during 2006-2007. The survey included 36 Likert-scaled items inquiring about residents' attitudes towards their psychotherapy training and supervision, their level of psychotherapy competence, the role of psychotherapy in their psychiatric identity, and their future practice plans. Four items asked about personal psychotherapy experience. Here we describe findings related to attitudes concerning being a psychotherapist and future practice plans. RESULTS: Among 249 respondents, most (82%) viewed becoming a psychotherapist as integral to their psychiatric identity. Fifty-four percent planned to provide formal psychotherapy, whereas 62% anticipated psychopharmacology would be the foundation of treatment for most patients. Residents with personal psychotherapy experience and first-year postgraduate residents (PGY-1) were more likely to identify as psychotherapists, plan to pursue further psychotherapy training postresidency, and anticipate psychotherapy being central to their future practice. CONCLUSIONS: Despite concerns about the diminishing role of psychotherapy in the practice of psychiatry and in psychiatrists' professional identity, most psychiatric residents view psychotherapy as integral to their professional identities and future practice plans.

Childhood sexual abuse severity and disclosure as predictors of depression among adult African-American and Latina women.

A history of childhood sexual abuse (CSA) has been associated with adult depression, but data on abuse severity and disclosure are scant, particularly among low-income ethnic minorities. CSA often co-occurs with other adversities, which also increase the risk of depression. This study examined the peritrauma variable of abuse severity and the posttrauma variables of disclosure and self-blame as predictors of current depression symptoms in 94 low-income African-American and Latina women with histories of CSA. After controlling for nonsexual childhood adversity and adult burden (i.e., chronic stress), severe CSA overall was associated with higher depression scores, especially among Latinas who disclosed their abuse. Depression symptoms among African-American women were highest in those who disclosed and reported high levels of self-blame at the time of the incident. The link between depression and specific peri- and post-CSA factors in minority women may help guide future interventions.

Psychiatric residents' interest in psychotherapy and training stage: a multi-site survey.

BACKGROUND: Most psychiatric residents enter training intent on learning both psychopharmacologic and psychotherapeutic interventions. After graduation, however, many emphasize pharmacotherapy over psychotherapy. METHODS: A multisite survey of psychiatry residents queried psychotherapy interests, attitudes, and practice intentions. Factors associated with self-reported decreased interest in psychotherapy since beginning residency were examined. RESULTS: Although 11.8% of the entire sample (n = 229 PGY1-PGY4 residents) reported decreased interest in psychotherapy during training, among PGY4s the corresponding figure was 16.4%. Positive attitudes towards psychotherapy, and self-perceived competence in cognitive-behavioral and psychodynamic psychotherapy were most highly correlated with maintained interest in psychotherapy. Dissatisfaction with the quality of psychotherapy faculty and curriculum, and viewing departmental leadership as unsupportive of psychotherapy training were correlated with decreased interest during training. CONCLUSIONS: Maintaining residents' interest in psychotherapy requires improvements in curriculum, teaching, and supervision throughout training. Our data underscore the crucial role that departmental leadership must play in supporting trainees' goals of becoming comprehensively trained psychiatrists.

Childhood sexual abuse severity and disclosure predict posttraumatic stress symptoms and biomarkers in ethnic minority women.

OBJECTIVE: Adult posttraumatic stress symptoms and a biomarker index of current health risk in childhood sexual abuse (CSA) survivors were investigated in relation to CSA severity, disclosure, and other peri- and post-trauma factors. METHOD: A community sample of 94 African American and Latina female CSA survivors was assessed. RESULTS: Severe CSA predicted posttraumatic stress symptoms overall, avoidance/numbing symptoms, and greater biomarker risk and was not mediated by post-trauma variables. Moderate CSA severity was mediated by post-trauma disclosure, predicted reexperiencing symptoms, but was unrelated to biomarker risk. No overall ethnic differences were found. CONCLUSION: Results suggest targets for interventions to improve the well-being of minority women CSA survivors.

Sexual health competence of international medical graduate psychiatric residents in the United States.

OBJECTIVE: Currently in the United States, more than one in three psychiatric residents are international medical graduates (IMGs). In light of forecasts of physician shortages, this proportion is likely to continue growing. Although central to psychiatric care, sexual health competence levels of IMGs may be lower than those of U.S. graduates. METHODS: The authors conducted a nonsystematic review of the literature and online data to establish the learning needs of IMGs in this area. RESULTS: Data on five areas are summarized: demographic and sociocultural data of IMGs in the United States; the need for sexual medicine competence for practicing psychiatrists; how sexual health is currently taught in foreign medical schools; attitudes toward sexuality and sexual problems among physicians and patients of different cultures; and the management of sexual issues, including sexual boundaries, by IMGs. CONCLUSION: The authors found evidence suggesting that IMGs from areas most culturally dissimilar to the United States are likely to benefit from sexual medicine curricula in the context of cultural competence training. The diversity and resilience of IMGs are emphasized. Implications for immediate training and future research are outlined.

Psychiatric residents' views of quality of psychotherapy training and psychotherapy competencies: a multisite survey.

OBJECTIVE: Few studies of residents' attitudes toward psychotherapy training exist. The authors examined residents' perceptions of the quality of their training, support for training, their own competence levels, and associations between self-perceived competence and perceptions of the training environment. METHODS: An anonymous, web-based questionnaire was distributed to residents at 15 U.S. training programs in 2006-2007. Likert-scaled items were used to evaluate attitudes regarding psychotherapy training and self-perceived competence in five modes of psychotherapy: brief, cognitive-behavioral, combined psychotherapy and psychopharmacology, psychodynamic, and supportive. RESULTS: Surveys were completed by 249 of 567 residents (43.9%). Over one-half agreed that their program provided high-quality psychotherapy training. Concerns about the adequacy of the time and resources provided by their programs were expressed by 28%. Although residents generally believed that their training directors supported psychotherapy training, approximately one-third did not believe that other key department leaders were supportive. Across years of training and modes of therapy, residents perceived their own competence in neutral to slightly positive terms, with self-perceived competence increasing with years of training. CONCLUSION: Given the current residency training requirements, these data provide a mixed picture about how residents experience psychotherapy training. Residency programs may need to reassess the quality and quantity of resources dedicated to psychotherapy training. Critical appraisal of support provided by key departmental leadership is also warranted.

Epigenetic mechanisms activated by childhood adversity.

Adverse childhood experiences (ACE) impair health and life expectancy and may result in an epigenetic signature that drives increased morbidity primed during early stages of life. This literature review focuses on the current evidence for epigenetic-mediated programming of brain and immune function resulting from ACE. To address this aim, a total of 88 articles indexed in PubMed before August 2019 concerning ACE and epigenetics were surveyed. Current evidence partially supports epigenetic programming of the hypothalamic-pituitary-adrenal axis, but convincingly shows that ACE impairs immune function. Additionally, the needs and challenges that face this area are discussed in order to provide a framework that may help to clarify the role of epigenetics in the long-lasting effects of ACE.