Ageism in the Mental Health Setting.

PURPOSE OF REVIEW: This paper summarizes the prevalence, impact, and presentation of ageism across multiple mental health care settings including inpatient, outpatient, long-term care, and criminal justice. Strategies for combating ageism are described. RECENT FINDINGS: Ageism is a common form of bias that has deleterious medical and psychosocial consequences for older adults. Ageism manifests in a variety of ways in mental health settings. Clinical, educational, and public policy strategies are recommended to combat ageism in mental health settings. Ageism remains pervasive in society and in mental health care settings. Ageism impacts healthcare trainees, healthcare providers, healthcare systems, and older adults themselves. Age-friendly practices and strategies for combating ageism exist and need broader dissemination.

Educating the Educator: Evaluation and Review of the ADMSEP Education Scholars Program.

OBJECTIVE: This report examines the first 8 years of the Association of Directors of Medical Student Education in Psychiatry (ADMSEP) Education Scholars Program (ESP) to determine the impact of the program on alumni careers and scholarship and their reception of the ESP. The 2-year longitudinal professional development program, launched in 2012, provides foundational knowledge to improve scholarship skills for faculty in psychiatry medical student education. The program is unique among national faculty development programs for psychiatry medical educators in its focus on scholarship and its requirement of completion of a research project in medical education.. METHODS: All 19 graduates of the program were sent a 30-question survey that explored alumni perceptions of the impact of the program on their confidence to engage in educational scholarship and on their careers. Quantitative and qualitative analyses were used to examine responses to the multiple choice and open-ended questions. A PubMed search was used to ascertain papers published by alumni since completion of the program. RESULTS: Graduate survey responses indicated a high level of satisfaction with the key elements of the program. Alumni respondents reported positive perceptions of participation in the program on their careers as well as on their interest, confidence, knowledge, and skills to engage in scholarship. Nine alumni have had scholarly work published since completion of the program. CONCLUSIONS: The ADMSEP ESP was highly valued by participants. It fills an important need for faculty in psychiatry medical student education by providing a national professional development program focused on scholarship.

The COVID-19 AAGP Online Trainee Curriculum: Development and Method of Initial Evaluation.

OBJECTIVE: One effect of the COVID-19 pandemic is the disruption of in-person clinical experiences within geriatric psychiatry residency education. Online resources for trainees are needed to fill resultant gaps. METHODS: The American Association of Geriatric Psychiatry (AAGP) Teaching and Training Committee leadership collaborated with geriatric psychiatry experts to develop a web-based geriatric psychiatry curriculum for psychiatry residents and other learners. In addition, we planned to obtain initial self-report outcomes of the curricular modules. RESULTS: The COVID-19 AAGP Online Trainee Curriculum (aagponline.org/covidcurriculum) consists of approximately 30 video-recorded lectures provided by AAGP member experts. A demographic survey and pre-/postsurvey attached to each module allow us to obtain learner characteristics and feedback on each module. CONCLUSIONS: The Curriculum has the potential to supplement psychiatry residency education during the pandemic and potentially raise the profile of AAGP, with the goal of inspiring interest within geriatric psychiatry. Results of the initial self-report evaluation should be available in 1 year.

Geriatric Psychiatry Teaching in Canadian Medical Schools: a Cross-Sectional Study.

OBJECTIVE: With a growing geriatric population and limited geriatric psychiatrists in Canada, it is crucial to provide sufficient training in geriatric psychiatry during medical school. The authors examined how geriatric psychiatry education is delivered in Canadian medical schools during clerkship. Factors that could be associated with increased geriatric psychiatry teaching in medical schools were examined. The authors were also interested in comparing Canadian to US findings. METHODS: A cross-sectional survey was distributed to the psychiatry medical education representatives attending the Canadian Organization of Undergraduate Psychiatry Educators (COUPE) semi-annual meeting in September 2017. RESULTS: All 17 (100%) medical schools completed the survey. Fifteen of the 17 schools (88%) have geriatric psychiatry-specific learning objectives. Five schools (29%) offer a clinical component in geriatric psychiatry. One school has an award for clerks (6%), and no awards exist for faculty. The number of lecture hours in geriatric psychiatry is moderately correlated with the presence of a geriatric component to psychiatry clerkship (Spearman's rho = 0.67, p = 0.003) and the length of the geriatric portion of clerkship (Spearman's rho = 0.64, p value = 0.006). Lecture hours are also moderately correlated with the presence of a geriatric fellowship (Spearman's rho = 0.68, p value = 0.003). CONCLUSIONS: Geriatric psychiatry clerkship education is inconsistent in Canada. There is virtually no recognition of excellence in teaching or undergraduate performance in this area in clerkship. Geriatric psychiatry may receive more frequent attention in Canadian medical schools than in US medical schools.

The association of antidepressant treatment with COPD maintenance medication use and adherence in a comorbid Medicare population: A longitudinal cohort study.

The effect of treating comorbid depression to achieve optimal management of chronic obstructive pulmonary disease (COPD) has not yet empirically tested. We examined the association between antidepressant treatment and use of and adherence to COPD maintenance medications among patients with new-onset COPD and comorbid depression. METHODS: Using 2006-2012 Medicare data, this retrospective cohort study identified patients with newly diagnosed COPD and new-onset major depression. Two exposures-antidepressant use (versus non-use) and adherence measured by proportion of days covered (PDC) (PDC ≥0.8 versus <0.8)-were assessed quarterly. We used marginal structural models to estimate the effects of prior antidepressant use and adherence on subsequent COPD maintenance inhaler use and adherence outcomes, accounting for time-varying confounders. RESULTS: A total of 25 458 COPD-depression patients, 82% with antidepressant treatment, were followed for a median of 2.5 years. Nearly half (48%) used at least 1 COPD maintenance inhaler in any given quarter; among users, 3 in 5 (61%) had a PDC of <0.8. Compared to patients with no antidepressant treatment, those with antidepressant use were more likely to use (relative ratio [RR] = 1.15, 95% confidence interval [CI] = 1.12- 1.17) and adhere to (RR = 1.08, 95% = 1.03-1.14) their COPD maintenance inhalers. Patients who adhered to antidepressant treatment were more likely to use and adhere to COPD maintenance inhalers. CONCLUSION: Regularly treated depression may increase use of and adherence to necessary maintenance medications for COPD. Antidepressant treatment may be a key determinant to improving medication-taking behaviors among COPD patients comorbid with depression.

Development of Geriatric Mental Health Learning Objectives for Medical Students: A Response to the Institute of Medicine 2012 Report.

America is aging as the population of older adults increases. The shortage of geriatric mental health specialists means that most geriatric mental healthcare will be provided by physicians who do not have specialty training in geriatrics. The Institute of Medicine Report of 2012 highlighted the urgent need for development of national competencies and curricula in geriatric mental health for all clinicians. Virtually all physicians can expect to treat older patients with mental health symptoms, yet currently there are no widely accepted learning objectives in geriatric mental health specific for medical students. The authors describe the development of a set of such learning objectives that all medical students should achieve by graduation. The iterative process included initial drafting by content experts from five medical schools with input and feedback from a wider group of geriatric psychiatrists, geriatricians, internists, and medical educators. The final document builds upon previously published work and includes specific knowledge, attitudes and skills in six key domains: Normal Aging, Mental Health Assessment of the Geriatric Patient, Psychopharmacology, Delirium, Depression, and Dementia. These objectives address a pressing need, providing a framework for national standards and curriculum development.

New episodes of depression among Medicare beneficiaries with chronic obstructive pulmonary disease.

OBJECTIVES: Depression is a common comorbidity of chronic obstructive pulmonary disease (COPD) and is associated with increased exacerbations, healthcare utilization, and mortality. Among Medicare beneficiaries newly diagnosed with COPD, the objectives of this study were to (1) estimate the rate of new episodes of depression and (2) identify factors associated with depression. METHODS: We identified beneficiaries with a first diagnosis of COPD during 2006-2012 using a 5% random sample of Medicare administrative claims data by searching for ICD-9-CM codes 490, 491.x, 492.x, 494.x, or 496. We identified episodes of depression using ICD-9-CM codes 296.2x, 296.3x, and 311.xx. We calculated incidence rates and their 95% confidence intervals (95% CI) and used a discrete time analysis to identify factors associated with development of depression. RESULTS: Between 2006 and 2012, 125,348 beneficiaries meeting inclusion criteria were newly diagnosed with COPD. Twenty-three percent developed depression following COPD diagnosis. The annualized incidence rate of depression per 100 beneficiaries following COPD diagnosis was 9.4 (95% CI 9.3, 9.5). Rates were highest in the first 2 months following COPD diagnosis. COPD diagnosis was associated with increased risk of depression (risk ratio 1.76; 95% CI 1.73, 1.79) as were COPD-related hospitalizations (risk ratio 4.59; 95% CI 4.09, 5.15), a measure of COPD severity. CONCLUSIONS: Diagnosis of COPD increases the risk of depression. This study will aid in the allocation of resources to monitor and provide support for individuals with COPD at high risk of developing depression.

Clinical Characteristics of Patients with Late Life Bipolar Disorder in the Community: Data from the NNDC Registry.

OBJECTIVE: To compare clinical characteristics of older and younger patients with bipolar disorder enrolled in the United States' National Network of Depression Centers (NNDC) Clinical Care Registry (CCR). DESIGN: Multicenter, de-identified naturalistic data from the National NNDC's CCR for all patients with a diagnosis of bipolar disorder who were enrolled in the registry as of April 25, 2013. PARTICIPANTS: Community-dwelling patients (N = 218), ages 18 years or older, with bipolar disorder diagnosis recruited by NNDC-affiliated medical centers to participate in the NNDC CCR. Subjects aged 55 years or older were compared with subjects younger than age 55 years on clinical measures. MEASUREMENTS: Patient Health Questionnaire; Quick Inventory of Depressive Symptomatology - Self-Report; Altman Self-Rating Mania Scale; Work and Social Adjustment Scale; Frequency and Intensity of Burden of Side Effects Rating; and the Self-Administered Comorbidity Questionnaire. RESULTS: A greater percentage of older patients were prescribed antidepressant medications (71.9% versus 50.0%), and the younger cohort had significantly more psychostimulant use (16.7% versus 0%). Younger patients endorsed significantly more depressive symptoms compared with older patients. The mean number of psychotropic medications was not different in both older and younger patients with bipolar disorder. There was no statistically significant difference in frequency, intensity, or burden of psychotropic medication side effects as measured by the Frequency and Intensity of Burden of Side Effects Rating. CONCLUSION: Findings of higher antidepressant use rates in the older cohort, combined with lower depression symptom severity and a similar degree of manic symptoms, suggests the possibility that older adults with bipolar disorder may have improved antidepressant efficacy and lower switch rates into manic or mixed states compared with younger cohorts. Ongoing data collection by the NNDC CCR will add to current knowledge to inform the care of older patients with bipolar disorder by providing multi-site data regarding phenomenology, treatment response, and longitudinal course of late life bipolar disorder in community settings.

Geriatric psychiatry in the psychiatry clerkship: a survey of current education practices.

OBJECTIVE: The aging of the US population and shortage of geriatric psychiatrists mean that all medical students must be prepared to evaluate psychiatric symptoms in older patients. The authors sought to describe current geriatric psychiatry teaching practices during the psychiatry clerkship. METHODS: Psychiatry clerkship directors at 110 American medical schools were surveyed about didactic and clinical experiences of geriatric psychiatry. RESULTS: Sixty-two (56 %) of programs responded. One fifth of programs lacked specific instruction in geriatric psychiatry. Programs were more likely to include instruction on dementia than late-life depression. Increased geriatric psychiatry educational offerings were associated with the following: number of geriatric psychiatrists on faculty, presence of a geriatric psychiatrist on the medical education committee, and inclusion of geriatric psychiatry specific items in clerkship learning objectives. CONCLUSIONS: Current practices in some clerkships are inadequate to prepare medical students to care for older patients with psychiatric symptoms.

The ADMSEP Education Scholars Program: a novel approach to cultivating scholarship among psychiatry educators.

The author describes the Association of Directors of Medical Student Education in Psychiatry's Education Scholars Program, a 2-year longitudinal, guided mentorship program, anchored by didactic instruction in the fundamental concepts of educational scholarship.

Living alone with dementia: lack of awareness adds to functional and cognitive vulnerabilities.

BACKGROUND: Approximately 25% of individuals with dementia live alone, yet little is known about the cognitive and functional factors that impact detection of impairment. METHODS: Subjects with dementia (n = 349) from a community study of dementia management were administered the Mini-mental State Examination (MMSE) and were asked to rate their cognitive status. Each participant's knowledgeable informant (KI) was interviewed to provide information about the subject's mental health and levels of cognitive and functional impairment. Subjects with dementia living alone (n = 97, 27.8%) were compared to subjects living with others (n = 252, 72.2%) regarding functional impairment, psychiatric symptoms, cognitive functioning, and dementia recognition. RESULTS: While subjects with dementia living alone had significantly fewer ADL impairments (p < 0.0001) and less cognitive impairment (p < 0.0001) than subjects with dementia who were living with others, nearly half of subjects living alone had two or more IADL impairments. Both knowledgeable informants (p < 0.001) and primary care physicians (p < 0.009) were less likely to detect dementia in subjects living alone, while 77.3% of subjects with dementia living alone rated their cognitive abilities as "good" or "a little worse". Subjects with dementia living alone and those living with others had similar rates of psychosis (p = 0.2792) and depressive symptoms (p = 0.2076). CONCLUSIONS: Lack of awareness of cognitive impairment by individuals with dementia living alone as well as their knowledgeable informants and physicians, combined with frequent functional impairment and psychiatric symptoms, heightens risk for adverse outcomes. These findings underscore the need for increased targeted screening for dementia and functional impairment among older persons living alone.

A longitudinal "teaching-to-teach" curriculum for psychiatric residents.

OBJECTIVE: Psychiatric residents' self-reported confidence levels related to teaching medical students were assessed before and after a five-part teaching seminar series. METHODS: Five 1-hour seminars on teaching medical students in the psychiatry clerkship were presented to second postgraduate year (PGY-2) residents. Topics included how to teach psychiatric interviewing, the mental status exam, case formulation, giving feedback, and evaluating student work. Residents were surveyed before and after the seminar series to assess their levels of confidence to teach specific skills. RESULTS: A greater percentage of PGY-2 residents rated themselves as "very confident" in teaching and providing feedback to medical students after the seminar series than before the series. The greatest increases were seen in confidence to teach interviewing skills, the mental status exam, psychiatric formulation, and to evaluate student work. CONCLUSION: A specific how-to-teach curriculum helped improve PGY-2 resident confidence for teaching medical students during the psychiatry clerkship.

Recognizing and Managing Geriatric Depression: A Two-Part Self-Learning Module Set.

INTRODUCTION: The number of geriatric patients will increase dramatically over the next 2 decades, and providers across all specialties will need skills in diagnosis and management of common geriatric disorders. Geriatric depression is common and associated with significant psychiatric and medical morbidity yet is frequently not taught in clinical clerkships. To provide foundational knowledge on geriatric depression, we designed a two-part, online, self-learning module set for health professions learners. METHODS: Learning objectives and content were chosen based upon consensus from a national panel of internal medicine and psychiatry clinician-educators. The two-part module set covers recognition of depression and use of screening tools for diagnosis, suicide assessment, patient education, and initial management approaches. Articulate software was used to create two complementary 20-minute modules that incorporate teaching points, interactive quizzes, and video clips of a clinician interviewing a standardized patient and her husband during the course of an initial clinical evaluation. RESULTS: The modules were piloted with 11 senior medical students. Mean number of correct answers on 10 knowledge-test questions improved from 8.1 on pretesting to 9.4 on posttesting. On a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree), participants affirmed that the modules were easy to navigate (4.91) and increased understanding of geriatric depression (4.82) and that the videos added to the learner's understanding of objectives (4.64). DISCUSSION: These modules can be used by learners in health professions schools to improve foundational knowledge in geriatric depression and prepare for advanced clinical work with older patients.