Frequency of metabolic syndrome in psychiatric patients, is this the time to develop a standardized protocol to reduce the morbidity from an acute care psychiatry unit.

OBJECTIVE: To determine the frequency of Metabolic Syndrome among psychiatric patients and to look for the correlation between the two medical conditions. METHODS: The cross-sectional study was conducted from February to April 2013 at the acute care psychiatry in-patient unit at Kingston General Hospital, Ontario, Canada, and comprised adult patients of both genders diagnosed under the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. For Metabolic Syndrome, definitions outlined by the International Diabetes Federation were used. The patients were divided into two groups on the basis of presence or absence of the Syndrome and were compared for clinical and demographic characteristics. SPSS 22 was used for statistical analysis. RESULTS: Of the 50 patients in the study, 24(48%) were found to have Metabolic Syndrome. Besides, 40 (80%) patients were taking atypical antipsychotics regardless of the diagnosis; 20(83%) among those with the Syndrome, and 20(77%) among those without it. CONCLUSIONS: Patients at high risk of developing metabolic syndrome need to be identified early so that an individualised care plan can be formulated. Identifying the variables to make a management plan is vital.

Systems-based aspects in the training of IMG or previously trained residents: comparison of psychiatry residency training in the United States, Canada, the United Kingdom, India, and Nigeria.

OBJECTIVES: International medical graduates (IMGs) account for a significant proportion of residents in psychiatric training in the United States. Many IMGs may have previously completed psychiatry residency training in other countries. Their experiences may improve our system. Authors compared and contrasted psychiatry residency training in the U.S. to that of Canada, the United Kingdom, India, and Nigeria. The study also highlights the systems-based features that may have an impact on the adaptation of IMGs (especially previously-trained) to U.S. psychiatry residency. METHODS: Individuals who are familiar with psychiatry residency training in the United States and were previously trained in other countries synthesized information available on websites, official documents, and previous literature, as well as their experiences with past training. RESULTS: Psychiatry residencies vary considerably in all five countries in terms of the duration of training, curriculum, clinical experience, psychotherapy training, research experience, supervision, and evaluation processes. Residency training in the U.S., Canada, and the U.K. is well-structured and has more psychotherapy training. The U.K. has enhanced exposure to community psychiatry. The U.K., India, and Nigeria have increased emphasis on psychopathology. Training in India and Nigeria has a higher quantity of clinical work, less record-keeping, less emphasis on patient autonomy, and a mandatory prospective clinical research requirement. CONCLUSIONS: The provision of services and training is substantially influenced by national mental health policies, culture, and local traditions. Despite numerous commonalities, there are some differences in psychiatry training among all five countries. Awareness of these differences in education, systems, and interactions may help psychiatric educators to understand IMGs (especially those previously-trained) as they adapt to U.S. training.

Changes in cardiorespiratory function and fatigue following 12 weeks of exercise training in women with systemic lupus erythematosus: a pilot study.

OBJECTIVE: In patients with systemic lupus erythematosus (SLE), fatigue is a debilitating symptom with poorly understood pathophysiology. Cardiorespiratory dysfunction has been hypothesised as a contributor to SLE-fatigue. The purpose of this exploratory study was to examine changes in cardiorespiratory function, following an exercise training programme in women with SLE, together with patient reported outcomes and other pathophysiological measures that may underlie SLE-fatigue. METHODS: Sixteen women with SLE and fatigue (Fatigue Severity Scale (FSS) ≥3) were enrolled in a supervised aerobic exercise training programme of vigorous intensity. The primary outcome was time to reach anaerobic threshold (AT-Time) during a cardiopulmonary exercise test (CPET). Secondary outcomes included changes in the 10-minute walk test (10MWT), FSS scores and the Patient Reported Outcomes Measurement Information System (PROMIS-57) survey. Mitochondrial function was assessed by the oxygen consumption rate (OCR)/extracellular acidification rate (ECAR) metabolic potential ratio. RESULTS: Following 12 weeks of exercise training, AT-Time increased by 93±82 (mean±SD) s (p<0.001), 10MWT increased by 84±66 m (p<0.001) and peak oxygen uptake (VO2) increased by 1.4±2.0 mL/kg/min (p=0.013). There were improvements in FSS score (-1.4±1.0, p<0.0001) and in most of the PROMIS-57 domains. The decrease in FSS scores correlated with an increase in the OCR/ECAR ratio (Pearson's correlation r=-0.59, p=0.03). A subset of subjects (9/15) had significant reduction in their Interferon Stimulated Genes (ISG) (p=0.007) accompanied by a significant increase in the OCR/ECAR ratio (p=0.013). CONCLUSIONS: Cardiorespiratory function was improved in concomitance with reductions in fatigue following a 12-week aerobic exercise programme. The reduction in fatigue scores correlated with improvements in mitochondrial function.

Prevalence of substance use disorder comorbidity among individuals with eating disorders: A systematic review and meta-analysis.

OBJECTIVE: Although prior meta-analyses have significantly enriched the available literature on the comorbidity of substance use disorders (SUD) among individuals with eating disorders (ED), there have been few, recent, comprehensive reviews, and limited meta-analyses that include a range of SUDs. METHOD: In accordance with the PRISMA guidelines, six electronic databases were searched, and a total of 1013 articles were identified using a combination of search terms to identify relevant prevalence studies: eating disorder, substance-related disorder, drug dependence, drug abuse, drug addiction, substance abuse, and prevalence. After two authors screened articles and extracted data independently, 43 articles met inclusion criteria. Data was coded, and a risk of bias assessment was conducted for each included study. Meta-analysis and moderator-analysis was carried out using random-effects modelling. RESULTS: The pooled lifetime and current prevalence of any comorbid SUD was 21.9% (95% CI 16.7-28.0) and 7.7% (95% CI 2.0-25.8), respectively. Tobacco (36.1 ±â€¯23.1%), caffeine (23.8 ±â€¯12.5%), and alcohol (20.6 ±â€¯16.0%) were the most prevalent SUD comorbidities. Higher prevalence was observed in all-female samples, primarily Caucasian samples, and binge-purge presentations. Neither lifetime nor current prevalence were associated with age. DISCUSSION: These results suggest that individuals with eating disorders should be regularly screened and offered treatment for substance use disorders concurrently during treatment for ED.

The association between borderline personality disorder, fibromyalgia and chronic fatigue syndrome: systematic review.

BACKGROUND: Overlap of aetiological factors and demographic characteristics with clinical observations of comorbidity has been documented in fibromyalgia syndrome, chronic fatigue syndrome (CFS) and borderline personality disorder (BPD). AIMS: The purpose of this study was to assess the association of BPD with fibromyalgia syndrome and CFS. The authors reviewed literature on the prevalence of BPD in patients with fibromyalgia or CFS and vice versa. METHODS: A search of five databases yielded six eligible studies. A hand search and contact with experts yielded two additional studies. We extracted information pertaining to study setting and design, demographic information, diagnostic criteria and prevalence. RESULTS: We did not identify any studies that specifically assessed the prevalence of fibromyalgia or CFS in patients with BPD. Three studies assessed the prevalence of BPD in fibromyalgia patients and reported prevalence of 1.0, 5.25 and 16.7%. Five studies assessed BPD in CFS patients and reported prevalence of 3.03, 1.8, 2.0, 6.5 and 17%. CONCLUSIONS: More research is required to clarify possible associations between BPD, fibromyalgia and CFS. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Attitudes of Canadian psychiatry residents if mentally ill: awareness, barriers to disclosure, and help-seeking preferences.

BACKGROUND: The medical culture is defined by mental illness stigma, non-disclosure, and avoidance of professional treatment. Little research has explored attitudes and help-seeking behaviors of psychiatry trainees if they were to become mentally ill. METHOD: Psychiatry residents (n = 106) from training centres across Ontario, Canada completed a postal survey on their attitudes, barriers to disclosure, and help-seeking preferences in the context of hypothetically becoming mentally ill. RESULTS: Thirty-three percent of respondents reported personal history of mental illness and the frequency of mental illness by year of training did not significantly differ. The most popular first contact for disclosure of mental illness was family and friends (n = 61, 57.5%). Frequent barriers to disclosure included career implications (n = 39, 36.8%), stigma (n = 11, 10.4%), and professional standing (n = 15, 14.2%). Personal history of mental illness was the only factor associated with in-patient treatment choice, with those with history opting for more formal advice versus informal advice. CONCLUSIONS: At the level of residency training, psychiatrists are reporting barriers to disclosure and help-seeking if they were to experience mental illness. A majority of psychiatry residents would only disclose to informal supports. Those with a history of mental illness would prefer formal treatment services over informal services.

A retrospective analysis of personality disorder presentations in a Canadian university-affiliated hospital's emergency department.

BACKGROUND: Individuals with personality disorders often have extensive involvement with healthcare services including frequent utilisation of emergency departments. AIMS: The aim of this study was to identify factors associated with emergency department presentations by individuals with personality disorders. METHOD: A 12-month retrospective data analysis of all mental-health-related emergency department visits was performed. Age, gender, time and season of presentation, length of stay, mode of arrival and discharge arrangements for individuals with personality disorders were compared to individuals with other psychiatric diagnoses. RESULTS: There were 336 visits by individuals with personality disorders and 5290 visits by individuals with other psychiatric diagnoses. Individuals with personality disorders were significantly more likely to be female, young adults, brought in by police, arrive in the evening, discharged home and have a longer median length of stay. CONCLUSION: Knowing what factors are associated with emergency department presentations by individuals with personality disorders can help ensure that appropriately trained support staff are available. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Do regulated resident working hours affect medical graduate education? Trends in the American psychiatry board pass rates pre- and post-2003 duty hours regulations.

Aims and method To assess trends of the American Board of Psychiatry and Neurology examination pass rates before and after the 2003 duty hours regulations (DHR). We obtained the pass rates for part I and II for years 2000-2010. Data were divided pre-DHR (2000-2003) and post-DHR (2007-2010). Results During the pre-DHR period, first- and multiple-attempt group pass rates were 80.7% and 39.0% which changed in the post-DHR period to 89.7% and 39.1% respectively. Similarly for the part II exam, the pre-DHR first- and multiple-attempt group pass rates were 60.2% and 43.5% respectively, which increased to 78.7% and 53.8%, among the post-DHR group. Overall, there was a significant increase in the first-attempt candidates pass rates for parts I and II, whereas multiple-attempt candidates did not benefit as strongly. Clinical implications The results suggest that the 2003 DHR may have had a positive impact on examination-based medical knowledge in psychiatry.

Clozapine reinitiation following a "red result" secondary to chemotherapy.

We describe a case of a patient whose clozapine was discontinued after a "red result" following R-CHOP (rituximab with cyclophosphamide, hydroxydaunorubicin, Oncovin, and prednisolone) chemotherapy for large B-cell lymphoma. In some cases, manufacturers grant permission, on compassionate grounds, for clozapine to be continued or reinitiated following assessment by their consultant hematologist. Other than a recent case report, there is not much literature surrounding this medical issue. However, since the two leading causes of mortality in schizophrenia are cancer and cardiac disease, this is not an uncommon occurrence. Clinicians are reluctant to prescribe clozapine in view of its side-effect profile, despite its proven efficacy for managing treatment-resistant schizophrenia. The alternative is to prescribe two antipsychotics to manage symptoms. This approach may be associated with increased side effects, and evidence for actual benefits is scant. The consequences were disastrous in this case, as the individual not only relapsed following clozapine discontinuation, but the therapy for this treatable form of lymphoma had to be delayed. He was eventually admitted to an inpatient unit after having been stable for 15 years. We managed to stabilize him with olanzapine and aripiprazole which enabled the heme-oncology group to resume R-CHOP therapy with filgrastim (granulocyte colony-stimulating factor). Even so, he continued to exhibit severe psychotic symptoms, with religious delusions and auditory hallucinations. We therefore applied for permission to rechallenge him on clozapine. Permission was granted when protocol conditions were met, and reinitiation went without any adverse events. The patient's symptoms showed improvement within a few weeks, and the other antipsychotics were discontinued once clozapine was titrated up to 300 mg. The decision to reinitiate clozapine following a red result is not to be taken lightly, but needs to be considered in terms of the risks versus benefits. More literature surrounding this issue would be of great benefit to clinicians, patients, and their families.

Treatment of anxiety disorders and comorbid alcohol abuse with buspirone in a patient with antidepressant-induced platelet dysfunction: a case report.

The risk of abnormal bleeding with serotonin reuptake inhibitors has been known, but there is insufficient evidence base to guide pharmacological treatment of anxiety in patients with underlying haematological conditions. The following case report is about a 50-year-old female with generalized anxiety disorder, social phobia, obsessive compulsive disorder, and alcohol abuse where pharmacological treatment of anxiety symptoms has been difficult as it would lead to bruising due to the patient's underlying qualitative platelet dysfunction. Treatment with venlafaxine, citalopram, escitalopram, and clomipramine resulted in improvement and anxiety symptoms, as well as reduction in alcohol use, but pharmacological treatment has to be discontinued because of bruising and hematomas. In view of an active substance use disorder, benzodiazepines were avoided as a treatment option. The patient's anxiety symptoms and comorbid alcohol abuse responded well to pharmacological treatment with buspirone which gradually titrated up to a dose of 30 mg BID. Patient was followed for around a six-month period while she was on buspirone before being discharged to family doctor's care. Buspirone is unlikely to have a significant effect on platelet serotonin transponder and could be an effective alternative for pharmacological treatment of anxiety in patients with a bleeding diathesis.

A preliminary report on resident emergency psychiatry training from a survey of psychiatry chief residents.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) requirements stipulate that psychiatry residents need to be educated in the area of emergency psychiatry. Existing research investigating the current state of this training is limited, and no research to date has assessed whether the ACGME Residency Review Committee requirements for psychiatry residency training are followed by psychiatry residency training programs. METHODS: We administered, to chief resident attendees of a national leadership conference, a 24-item paper survey on the types and amount of emergency psychiatry training provided by their psychiatric residency training programs. Descriptive statistics were used in the analysis. RESULTS: Of 154 surveys distributed, 111 were returned (72% response rate). Nearly one-third of chief resident respondents indicated that more than 50% of their program's emergency psychiatry training was provided during on-call periods. A minority indicated that they were aware of the ACGME program requirements for emergency psychiatry training. While training in emergency psychiatry occurred in many programs through rotations-different from the on-call period-direct supervision was available during on-call training only about one-third of the time. CONCLUSIONS: The findings suggest that about one-third of psychiatry residency training programs do not adhere to the ACGME standards for emergency psychiatry training. Enhanced knowledge of the ACGME requirements may enhance psychiatry residents' understanding on how their programs are fulfilling the need for more emergency psychiatry training. Alternative settings to the on-call period for emergency psychiatry training are more likely to provide for direct supervision.

Postgraduate year-1 residency training in emergency psychiatry: an acute care psychiatric clinic at a community mental health center.

OBJECTIVE: The purpose of this study was to determine resident satisfaction with an acute care psychiatric clinic designed in collaboration with a nearby community mental health center. We also sought to demonstrate that this rotation helps meet program requirements for emergency psychiatry training, provides direct assessments of resident interviewing skills and clinical knowledge in the postgraduate year-1, and provides exposure to public sector systems of care. METHODS: We developed a resident satisfaction questionnaire and fielded it to each of the residents who participated in the clinic over the first 3 years. Data were collected, organized, and analyzed. RESULTS: Of the 15 residents in the acute care psychiatric clinic, 12 completed and returned the satisfaction questionnaires. Educational aspects of the clinic experience were rated favorably. CONCLUSIONS: This postgraduate year-1 acute care psychiatric clinic provides a mechanism for the fulfillment of emergency psychiatry training as well as direct supervision of clinical encounters, which is a satisfactory and useful educational experience for trainees.