Early Clinical Exposure to Geriatric Psychiatry and Medical Students' Interest in Caring for Older Adults: A Randomized Controlled Trial.

OBJECTIVE: In the next 25 years, the population aged 65 and older will nearly double in many countries, with few new doctors wishing to care for older adults. The authors hypothesize that early clinical exposure to elderly patient care could increase student interest in caring for older adults during their future career. METHODS: The authors conducted a pragmatic medical education randomized controlled trial (RCT) at the Jewish General Hospital and the Douglas Mental Health Institute, McGill University, in Montreal, Canada. Third-year medical students undergoing their mandatory 16-week half-time clerkship rotation in psychiatry were randomly assigned to the equivalent of 2-4 weeks of full-time exposure to clinical geriatric psychiatry (n = 84). RESULTS: Being randomly assigned to geriatric psychiatry exposure (n = 44 of 84) was associated with increased "comfort in working with geriatric patients and their families" at 16-week follow-up (59.1% versus 37.5%, χ2 (1) = 3.9; p = 0.05). However, there was no significant association found between geriatric psychiatry exposure and change "in interest in caring for older adults," or change in "interest in becoming a geriatric psychiatrist." CONCLUSION: The results of this pragmatic education RCT suggest that exposing third-year medical students to 2-4 weeks of geriatric psychiatry did not increase their interest to care for older adults or become a geriatric psychiatrist. However, it did increase their comfort level in working with older adults and their families. However, more research is necessary to identify potential interventions that could inspire and increase medical student interest in caring for older adults as part of their future careers.

End-of-Life Care Preferences in Patients with Severe and Persistent Mental Illness and Chronic Medical Conditions: A Comparative Cross-Sectional Study.

OBJECTIVES: Physicians rarely engage severe and persistent mental illness (SPMI) patients in end-of-life care discussion despite an increased risk of debilitating medical illnesses and mortality. Access to quality palliative care and medical assistance in dying (MAID) has become a priority in Canada and many jurisdictions. In this study, we compared SPMI and chronic medically ill (CMI) patients' end-of-life care preferences and comfort level with end-of-life care discussion, and identified potential predictors of interest in MAID. DESIGN: Comparative cross-sectional study. SETTING: Hospital-based. PARTICIPANTS: We recruited 106 SPMI and 95 CMI patients at the Jewish General Hospital, Canada. Patients aged ≥40 years, without severe cognitive impairment, able to communicate in English or French and provide written informed consent were included. MEASUREMENTS: Attitudes towards pain management, palliative sedation, MAID, and artificial life support were collected with the Health Care Preferences Questionnaire. Adjusted odd ratios (aOR) were calculated for each end-of-life care intervention. Comfort with discussion was rated on a Likert scale. A stepwise regression analysis was performed to identify predictors of interest in MAID. RESULTS: SPMI was not correlated to any end-of-life care intervention, except for MAID where SPMI patients were less likely to support its use (aOR: 0.48, 95% CI: 0.25-0.94, p = 0.03). Religiosity was also correlated with interest in MAID (aOR: 0.14, 95% CI: 0.06-0.31, p < 0.001). Patients in both groups were comfortable talking about end-of-life care. CONCLUSIONS: SPMI patients are able to voice their end-of-life care preferences, and contrary to some fears, do not want MAID more than CMI patients.

Therapist interventions using the Psychodynamic Interventions Rating Scale (PIRS) in dynamic therapy, psychoanalysis and CBT.

One requirement for psychotherapy research is an accurate assessment of therapeutic interventions across studies. This study compared frequency and depth of therapist interventions from a dynamic perspective across four studies, conducted in four countries, including three treatment arms of psychodynamic psychotherapy, and one each of psychoanalysis and CBT. All studies used the Psychodynamic Intervention Rating Scales (PIRS) to identify 10 interventions from transcribed whole sessions early and later in treatment. The PIRS adequately categorized all interventions, except in CBT (only 91-93% categorized). As hypothesized, interpretations were present in all dynamic therapies and relatively absent in CBT. Proportions of interpretations increased over time. Defense interpretations were more common than transference interpretations, which were most prevalent in psychoanalysis. Depth of interpretations also increased over time. These data can serve as norms for measuring where on the supportive-interpretive continuum a dynamic treatment lies, as well as identify potentially mutative interventions for further process and outcome study.

An investigation of tasks and techniques associated with dynamic interview adequacy.

We examined the hypotheses that adequately conducted dynamic interviews would be associated with performance on five interview tasks, which, in turn, would be associated with specific clinical techniques. Ten subjects provided two dynamic interviews each, one rated higher and one lower in overall dynamic adequacy. Interviews were independently rated for completion of five interviewer tasks. Another rater independently categorized each therapist intervention as one of 10 therapeutic interventions. Dynamic interview adequacy was associated with four of five interview tasks, attributable to the interviewer's contribution, after controlling for the subject's contribution. Four tasks-frame setting, exploration of affect, interpretation, and synthesis-were associated with specific clinical interventions, whereas offering support was not. The overall thoroughness of completing the interview tasks was highly associated with dynamic adequacy and the ratio of exploratory to supportive interventions. The adequately conducted dynamic interview is associated with identifiable tasks and techniques that should facilitate teaching it for research or clinical use.