Psychiatry Clinical Skills Evaluation: a Multisite Study of Validity.

OBJECTIVE: Since 2007, the American Board of Psychiatry and Neurology (ABPN) has required that residency programs conduct a specific clinical skills evaluation (CSE) of physician-patient interaction, psychiatric interview and mental status examination, and case presentation on a directly observed patient interview as a prerequisite for certification. The authors examined a multisite database of CSE assessments to investigate the validity of the evaluation. METHODS: The authors collected 1156 CSE assessments from 4 residency programs conducted over a 6-year period, compared scoring patterns among the programs, score improvement over 4 years of residency, time and number of CSEs required to meet ABPN requirements, and patterns of scoring for individual faculty evaluators. RESULTS: The distribution of scores within each of the 4 programs showed similar, but nonidentical patterns. The number of CSEs required to meet the ABPN standards (3.5) and the point in training at which this was completed (late PGY-2) were the same in all programs. CSE scores were highly correlated with year of training but were not correlated with performance on an unrelated cognitive examination. Individual faculty members tended to stay within a moderate range of scores over multiple residents, partially attributable to year of training. CONCLUSIONS: Taken together, these findings support the validity of the CSE as a measure of residents' clinical skills in the specified areas and demonstrate a moderate-high degree of consistency in the scoring of the CSE across these 4 programs.

DSM-5 Teaching Materials: A Critical Review.

OBJECTIVE: The publication of DSM-5 by the American Psychiatric Association (APA) in 2013 was accompanied by the release of a series of APA-approved "essential guides" to aid clinicians and trainees in its use and the transition from DSM-IV. Several of these were explicitly designated as study guides, but all serve educational as well as clinical functions. To assist trainees and educators in their selection of appropriate materials for study and teaching, several of these books were reviewed from the perspective of psychiatry education. METHODS: DSM-5 and seven of the 11 essential guides featured on the American Psychiatric Publishing website were selected for review as to their value as education tools and the audience most likely to find them useful. RESULTS: Four of the books reviewed were intended as teaching tools; two were designated as aids to clinicians, but with novice practitioners specifically included as target users; and two were not designed as teaching tools at all, but only as clinical manuals. All eight of these books had significant value as texts or teaching tools, although they differed significantly in the quality and uniqueness of their content, their specific focus, and the readers for whom they would be most helpful. CONCLUSION: DSM-5 and the essential guides that accompany it have significant value as texts and study guides for teachers and trainees and make a valuable contribution to psychiatry education.

Management of older adults with dementia who present to emergency services with neuropsychiatric symptoms.

OBJECTIVE: Our aim is to evaluate if and how neuropsychiatric symptoms (NPS) of dementia influence the management and disposition of older adults who present to emergency care settings. METHODS: This is a retrospective cohort study that involved the medical and psychiatric emergency departments of a tertiary academic medical center. Participants included patients ≥65 years of age with dementia who presented between 1 February 2012 and 16 July 2014 (n = 347). Subjects with documented NPS (n = 78) were compared with a group of subjects without documented NPS (n = 78) randomly selected from the overall group with dementia. The groups with and without NPS were compared on demographic, clinical, management, and disposition characteristics. RESULTS: Patients with NPS were more likely to have additional diagnostic testing performed and receive psychotropic medications including benzodiazepines and antipsychotics. Significantly fewer patients with NPS (59.0%) returned to their original setting from the emergency department than patients without NPS (76.9%). Among patients with NPS, those who had a motor disturbance were more likely to receive psychotropic medications than patients who did not have a motor disturbance. Depression/dysphoria, anxiety, disinhibition, irritability/lability, and motor disturbance were all associated with transfer from medical to psychiatric emergency department. Patients with depression/dysphoria or anxiety were more likely to be psychiatrically hospitalized. CONCLUSIONS: There are significant differences in the management of dementia with and without NPS in the emergency room setting. Developing and implementing successful methods to manage NPS in the emergency department and outpatient setting could potentially lead to less emergent psychotropic administration and reduce hospitalizations. Copyright © 2016 John Wiley & Sons, Ltd.

Antipsychotics, other psychotropics, and the risk of death in patients with dementia: number needed to harm.

IMPORTANCE: Antipsychotic medications are associated with increased mortality in older adults with dementia, yet their absolute effect on risk relative to no treatment or an alternative psychotropic is unclear. OBJECTIVE: To determine the absolute mortality risk increase and number needed to harm (NNH) (ie, number of patients who receive treatment that would be associated with 1 death) of antipsychotic, valproic acid and its derivatives, and antidepressant use in patients with dementia relative to either no treatment or antidepressant treatment. DESIGN, SETTING, AND PARTICIPANTS: A retrospective case-control study was conducted in the Veterans Health Administration from October 1, 1998, through September 30, 2009. Participants included 90,786 patients 65 years or older with a diagnosis of dementia. Final analyses were conducted in August 2014. EXPOSURES: A new prescription for an antipsychotic (haloperidol, olanzapine, quetiapine, and risperidone), valproic acid and its derivatives, or an antidepressant (46,008 medication users). MAIN OUTCOMES AND MEASURES: Absolute change in mortality risk and NNH over 180 days of follow-up in medication users compared with nonmedication users matched on several risk factors. Among patients in whom a treatment with medication was initiated, mortality risk associated with each agent was also compared using the antidepressant group as the reference, adjusting for age, sex, years with dementia, presence of delirium, and other clinical and demographic characteristics. Secondary analyses compared dose-adjusted absolute change in mortality risk for olanzapine, quetiapine, and risperidone. RESULTS: Compared with respective matched nonusers, individuals receiving haloperidol had an increased mortality risk of 3.8% (95% CI, 1.0%-6.6%; P < .01) with an NNH of 26 (95% CI, 15-99); followed by risperidone, 3.7% (95% CI, 2.2%-5.3%; P < .01) with an NNH of 27 (95% CI, 19-46); olanzapine, 2.5% (95% CI, 0.3%-4.7%; P = .02) with an NNH of 40 (95% CI, 21-312); and quetiapine, 2.0% (95% CI, 0.7%-3.3%; P < .01) with an NNH of 50 (95% CI, 30-150). Compared with antidepressant users, mortality risk ranged from 12.3% (95% CI, 8.6%-16.0%; P < .01) with an NNH of 8 (95% CI, 6-12) for haloperidol users to 3.2% (95% CI, 1.6%-4.9%; P < .01) with an NNH of 31 (95% CI, 21-62) for quetiapine users. As a group, the atypical antipsychotics (olanzapine, quetiapine, and risperidone) showed a dose-response increase in mortality risk, with 3.5% greater mortality (95% CI, 0.5%-6.5%; P = .02) in the high-dose subgroup relative to the low-dose group. When compared directly with quetiapine, dose-adjusted mortality risk was increased with both risperidone (1.7%; 95% CI, 0.6%-2.8%; P = .003) and olanzapine (1.5%; 95% CI, 0.02%-3.0%; P = .047). CONCLUSIONS AND RELEVANCE: The absolute effect of antipsychotics on mortality in elderly patients with dementia may be higher than previously reported and increases with dose.

Medical education teaching resources.

OBJECTIVE: Numerous monographs on psychiatry education have appeared without a review specifically intended to assist psychiatry faculty and trainees in the selection of appropriate volumes for study and reference. The authors prepared this annotated bibliography to fill that gap. METHODS: The authors identified titles from web-based searches of the topics "academic psychiatry," "psychiatry education," and "medical education," followed by additional searches of the same topics on the websites of major publishers. Forty-nine titles referring to psychiatry education specifically and medical education generally were identified. The authors selected works that were published within the last 10 years and remain in print and that met at least one of the following criteria: (1) written specifically about psychiatry or for psychiatric educators; (2) of especially high quality in scholarship, writing, topic selection and coverage, and pertinence to academic psychiatry; (3) covering a learning modality deemed by the authors to be of particular interest for psychiatry education. RESULTS: The authors reviewed 19 books pertinent to the processes of medical student and residency education, faculty career development, and education administration. These included 11 books on medical education in general, 4 books that focus more narrowly on the field of psychiatry, and 4 books addressing specific learning modalities of potential utility in the mental health professions. CONCLUSION: Most of the selected works proved to be outstanding contributions to the medical education literature.

Describing the relationship between cat bites and human depression using data from an electronic health record.

Data mining approaches have been increasingly applied to the electronic health record and have led to the discovery of numerous clinical associations. Recent data mining studies have suggested a potential association between cat bites and human depression. To explore this possible association in more detail we first used administrative diagnosis codes to identify patients with either depression or bites, drawn from a population of 1.3 million patients. We then conducted a manual chart review in the electronic health record of all patients with a code for a bite to accurately determine which were from cats or dogs. Overall there were 750 patients with cat bites, 1,108 with dog bites, and approximately 117,000 patients with depression. Depression was found in 41.3% of patients with cat bites and 28.7% of those with dog bites. Furthermore, 85.5% of those with both cat bites and depression were women, compared to 64.5% of those with dog bites and depression. The probability of a woman being diagnosed with depression at some point in her life if she presented to our health system with a cat bite was 47.0%, compared to 24.2% of men presenting with a similar bite. The high proportion of depression in patients who had cat bites, especially among women, suggests that screening for depression could be appropriate in patients who present to a clinical provider with a cat bite. Additionally, while no causative link is known to explain this association, there is growing evidence to suggest that the relationship between cats and human mental illness, such as depression, warrants further investigation.

Assessment of decision-making capacity: views and experiences of consultation psychiatrists.

BACKGROUND: Decision-making capacity (DMC) assessments can have profound consequences for patients. With an aging population, an increasing emphasis on shared decision-making, and a rising number of potential medical interventions, the need for such assessments will continue to grow. OBJECTIVE: To assess psychosomatic medicine clinicians' training, experiences, and views about DMC assessments. METHOD: Online survey of members of the Academy of Psychosomatic Medicine (APM). Of 780 eligible members, 288 responded to the survey (36.9% response rate). RESULTS: Approximately 1 in 6 psychiatric consultations are DMC assessments. Ninety percent of respondents reported that at least half of their capacity assessments involve patients older than 60 years. DMC assessments were seen as more challenging and time-consuming than other types of consultations; yet training in capacity evaluations was seen as suboptimal and half of respondents felt the evidence-base guiding DMC assessment is somewhat or much weaker than for other types of psychiatric consultations. In addition, the practice of capacity assessment seems to vary widely with no consistent approach among respondents. Respondents strongly endorsed multiple areas and topics for potential future research, indicating a desire for a stronger evidence-base. CONCLUSIONS: Members of the APM perceive capacity assessments as common and challenging. Yet they perceive having received subpar training with relatively weak evidence to guide their current practice. Future research should address these potential deficiencies, given the likelihood that DMC assessments will only become more common.

Mortality risk with the use of atypical antipsychotics in later-life bipolar disorder.

INTRODUCTION: In recent years, concerns about the use of antipsychotic medications in dementia have grown. There is limited data on mortality risk of atypical antipsychotics for other psychiatric disorders of later life such as bipolar disorder. METHODS: Data were derived from the national Department of Veterans Affairs registries for older patients with bipolar disorder (≥65 years) with a new start of an atypical antipsychotic (risperidone, olanzapine, or quetiapine) or valproic acid and derivatives during fiscal years 2001-2008. Six-month mortality rates were compared for individual drug groups. RESULTS: The sample included 4717 patients. The risperidone cohort had the highest mortality rate (11.8 per 100 person-years) with the quetiapine and valproic acid cohorts having the lowest (5.3 and 4.6 per 100 person-years, respectively). Various methods to adjust for baseline differences including propensity models showed similar patterns. CONCLUSIONS: Among older patients with bipolar disorder, there may be differences in mortality risks among individual antipsychotic agents.

Risk of mortality among individual antipsychotics in patients with dementia.

OBJECTIVE: The use of antipsychotics to treat the behavioral symptoms of dementia is associated with greater mortality. The authors examined the mortality risk of individual agents to augment the limited information on individual antipsychotic risk. METHOD: The authors conducted a retrospective cohort study using national data from the U.S. Department of Veterans Affairs (fiscal years 1999-2008) for dementia patients age 65 and older who began outpatient treatment with an antipsychotic (risperidone, olanzapine, quetiapine, or haloperidol) or valproic acid and its derivatives (as a nonantipsychotic comparison). The total sample included 33,604 patients, and individual drug groups were compared for 180-day mortality rates. The authors analyzed the data using multivariate models and propensity adjustments. RESULTS: In covariate-adjusted intent-to-treat analyses, haloperidol was associated with the highest mortality rates (relative risk=1.54, 95% confidence interval [CI]=1.38-1.73) followed by risperidone (reference), olanzapine (relative risk=0.99, 95% CI=0.89-1.10), valproic acid and its derivatives (relative risk=0.91, 95% CI=0.78-1.06), and quetiapine (relative risk=0.73, 95% CI=0.67-0.80). Propensity-stratified and propensity-weighted models as well as analyses controlling for site of care and medication dosage revealed similar patterns. The mortality risk with haloperidol was highest in the first 30 days but decreased significantly and sharply thereafter. Among the other agents, mortality risk differences were most significant in the first 120 days and declined in the subsequent 60 days during follow-up. CONCLUSIONS: There may be differences in mortality risks among individual antipsychotic agents used for treating patients with dementia. The use of valproic acid and its derivatives as alternative agents to address the neuropsychiatric symptoms of dementia may carry associated risks as well.

Predictors of suicide in patients with dementia.

BACKGROUND: Assessing predictors of suicide and means of completion in patients with dementia may aid the development of interventions to reduce risk of suicide among the growing population of individuals with dementia. METHODS: This national, retrospective, cohort study used data from the Department of Veterans Affairs (fiscal years 2001-2005). The sample included patients ≥60 years old diagnosed with dementia (N = 294,952), of which 241 committed suicide. Potential predictors of suicide were identified using logistic regression. Suicide methods are also reported. RESULTS: Increased risk of suicide was associated with white race (OR: 2.4, 95% CI: 1.2, 4.8), depression (OR: 2.0, 95% CI: 1.5, 2.9), a history of inpatient psychiatric hospitalizations (OR: 2.3, 95% CI: 1.5, 3.5), and prescription fills of antidepressants (OR: 2.1, 95% CI: 1.6, 2.8) or anxiolytics (OR: 2.0, 95% CI: 1.5, 2.7). Nursing home admission was associated with lower suicide risk (OR: 0.3, 95% CI: 0.1, 0.8). Severity of medical comorbidity did not affect risk of suicide. Sensitivity analysis indicated that the majority of suicides occurred in those who were newly diagnosed with dementia. Firearms were the most common method of suicide (73%) used. CONCLUSIONS: Given the higher rate of suicide in those receiving treatment for psychiatric symptoms and the high proportion that died using firearms, closer monitoring and assessment of gun access may be an important part of initial treatment planning for older male patients with dementia, particularly those with symptoms of depression or anxiety.

Psychosocial predictors of lower urinary tract symptom bother in black men: the Flint Men's Health Study.

PURPOSE: Despite the importance of lower urinary tract symptom related bother to health related quality of life and treatment use little is known about factors contributing to perceived bother. We examined associations between several psychosocial measures and lower urinary tract symptom related bother in a population based sample of black men. MATERIALS AND METHODS: In 1996, 361 black men 40 to 79 years old from Genesee County, Michigan with no history of prostate cancer/surgery provided information on lower urinary tract symptom bother and several psychosocial factors, including perceived stress, social support, stressful life events, and self-rated physical and emotional health. Associations between these factors and perceived bother were examined, controlling for age and lower urinary tract symptom severity. RESULTS: Overall 39.3% of men reported moderate/severe lower urinary tract symptom related bother. Men with poor emotional health and low social support were 2.25 (95% CI 1.05, 4.85) and 2.89 (95% CI 1.14, 7.35) times more likely to report moderate and severe bother, respectively. No other psychosocial factors significantly impacted bother after adjusting for age and lower urinary tract symptom severity. CONCLUSIONS: In this population based study of black men poor emotional health and low social support were significantly associated with moderate/severe lower urinary tract symptom related bother after adjusting for age and lower urinary tract symptom severity, supporting the notion that urinary bother measures may capture somatic and psychological distress. These findings suggest that treating lower urinary tract symptoms alone may not completely ameliorate urinary bother if underlying emotional health and social support problems are not addressed. Further studies are warranted in racially diverse populations.

Enhanced identification of eligibility for depression research using an electronic medical record search engine.

PURPOSE: Electronic medical records (EMRs) have become part of daily practice for many physicians. Attempts have been made to apply electronic search engine technology to speed EMR review. This was a prospective, observational study to compare the speed and clinical accuracy of a medical record search engine vs. manual review of the EMR. METHODS: Three raters reviewed 49 cases in the EMR to screen for eligibility in a depression study using the electronic medical record search engine (EMERSE). One week later raters received a scrambled set of the same patients including 9 distractor cases, and used manual EMR review to determine eligibility. For both methods, accuracy was assessed for the original 49 cases by comparison with a gold standard rater. RESULTS: Use of EMERSE resulted in considerable time savings; chart reviews using EMERSE were significantly faster than traditional manual review (p=0.03). The percent agreement of raters with the gold standard (e.g. concurrent validity) using either EMERSE or manual review was not significantly different. CONCLUSIONS: Using a search engine optimized for finding clinical information in the free-text sections of the EMR can provide significant time savings while preserving clinical accuracy. The major power of this search engine is not from a more advanced and sophisticated search algorithm, but rather from a user interface designed explicitly to help users search the entire medical record in a way that protects health information.