Caring Contacts to Reduce Psychiatric Morbidity Following Hospitalization During the COVID-19 Pandemic: A Pilot Randomized Controlled Trial.

OBJECTIVES: Caring Contacts are an emerging intervention that aims to reduce distress and suicide risk after acute psychiatric care. This trial aimed to determine whether, during a pandemic, there was any evidence that the mental health benefits and reduction in suicidal ideation (SI) associated with delivering Caring Contacts to recently discharged psychiatric patients were greater than a control communication. The secondary objective was to identify whether the predicted benefits were greater among people living alone or those diagnosed with depression. METHOD: A single-site pilot randomized clinical trial (n = 100), with patients recruited from the adult Inpatient Psychiatry Unit at Sunnybrook Health Sciences Centre, Toronto, Canada between August 2020 and May 2021. Participants were randomized (1:1) to the Caring Contact or control group. Participants received three Caring Contact or control communications via email or mail (on days 4, 21, and 56 post-discharge). Mental health symptoms were assessed using the self-report Hopkins Symptom Checklist-25 (HSCL-25) scores at discharge (baseline) and when participants received each communication. Analysis of variance was used for the primary comparisons and exploratory analyses for subgroups. RESULTS: Both groups experienced a significant worsening of mental health symptoms at all time points post-discharge relative to baseline. There were no significant differences between groups at any time point, however, on day 4 there was a 24.2% and 72.6% attenuated worsening in the Caring Contact group compared to the control group for total symptom severity and SI, respectively. There was no significant interaction effect for the depression subgroup or those living alone. CONCLUSIONS: While this pilot study was not powered to identify significant differences between groups, results are indicative of feasibility and acceptability of the intervention and provide some indication that Caring Contacts may have benefited patients in the days following discharge, supporting the need for larger-scale trials. The study was registered with clinicaltrials.gov (study ID NCT04456062).

Treatment-resistant major depressive disorder: Canadian expert consensus on definition and assessment.

BACKGROUND: Treatment-resistant depression (TRD) is a debilitating chronic mental illness that confers increased morbidity and mortality, decreases the quality of life, impairs occupational, social, and offspring development, and translates into increased costs on the healthcare system. The goal of this study is to reach an agreement on the concept, definition, staging model, and assessment of TRD. METHODS: This study involved a review of the literature and a modified Delphi process for consensus agreement. The Appraisal of Guidelines for Research & Evaluation II guidelines were followed for the literature appraisal. Literature was assessed for quality and strength of evidence using the grading, assessment, development, and evaluations system. Canadian national experts in depression were invited for the modified Delphi process based on their prior clinical and research expertize. Survey items were considered to have reached a consensus if 80% or more of the experts supported the statement. RESULTS: Fourteen Canadian experts were recruited for three rounds of surveys to reach a consensus on a total of 27 items. Experts agreed that a dimensional definition for treatment resistance was a useful concept to describe the heterogeneity of this illness. The use of staging models and clinical scales was recommended in evaluating depression. Risk factors and comorbidities were identified as potential predictors for treatment resistance. CONCLUSIONS: TRD is a meaningful concept both for clinical practice and research. An operational definition for TRD will allow for opportunities to improve the validity of predictors and therapeutic options for these patients.

Compassion Fatigue in Surgical Trainees.

OBJECTIVE: Compassion fatigue (CF) is the profound sense of emotional exhaustion that care providers can experience as the result of helping others in distress. CF can contribute to burnout (BO), depression, and stress-related illness. While surgeons and surgical trainees may be at high risk for developing CF, it has not been adequately characterized or explored in this population. The objective of this study was to examine the prevalence and impact of CF in surgical trainees with a view to inform a management strategy. STUDY DESIGN AND SETTING: A mixed method study was conducted using survey and interview methods. An email survey including the Professional Quality of Life Scale Version 5, an instrument to assess CF, was sent to all trainees in the Department of Surgery at the University of Toronto. Survey data were analyzed descriptively and using one-sample t tests. Semistructured interviews were conducted with volunteered trainees. Data collection and analysis occurred iteratively and inductively using the constant comparison method. RESULTS: One hundred fifteen trainees completed the survey representing a 47% response rate. Ninety-nine respondents (40.7%) completed the Professional Quality of Life Scale tool. The mean score on the compassion satisfaction subscale was 36.9 (SD 6.7), on the BO subscale was 26.2 (SD 5.6), and on the secondary traumatic stress (STS) subscale was 21.2 (SD 6.3). The mean on the compassion satisfaction subscale was not statistically different from the population mean (p = 0.22). The means for the BO and STS scales were statistically higher in our study sample compared to the normative data (p < 0.0001 for each). Thematic qualitative findings indicated trainees experienced CF symptoms. Participants described systemic barriers to mitigating CF including workload and a cultural expectation to be unemotional at work. CONCLUSION: Surgical trainees report high levels of BO and STS and currently use informal coping strategies outside of their academic and hospital environments. Trainees are likely to welcome and benefit from an organized response to support their emotional health when facing difficult patient encounters.

Assessment and Management of Posttraumatic Stress Disorder.

PURPOSE: The goal of this article is to increase clinicians' understanding of posttraumatic stress disorder (PTSD) and improve skills in assessing risk for and diagnosing PTSD. The importance and sequelae of lifetime trauma burden are discussed, with reference to trends in prevention, early intervention, and treatment. RECENT FINDINGS: PTSD has different clinical phenotypes, which are reflected in the changes in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. PTSD is almost always complicated by comorbidity. Treatment requires a multimodal approach, usually including medication, different therapeutic techniques, and management of comorbidity. Interest is growing in the neurobiology of childhood survivors of trauma, intergenerational transmission of trauma, and long-term impact of trauma on physical health. Mitigation of the risk of PTSD pretrauma in the military and first responders is gaining momentum, given concerns about the cost and disability associated with PTSD. Interest is also growing in screening for PTSD in medical populations, with evidence of improved clinical outcomes. Preliminary research supports the treatment of PTSD with repetitive transcranial magnetic stimulation. SUMMARY: PTSD is a trauma-related disorder with features of fear and negative thinking about the trauma and the future. Untreated, it leads to ongoing disruption of life due to avoidance, impaired vocational and social functioning, and other symptoms, depending on the phenotype. Despite a theoretical understanding of underlying mechanisms, PTSD remains challenging to treat, although evidence exists for benefit of pharmacologic agents and trauma-focused therapies. A need still remains for treatments that are more effective and efficient, with faster onset.

What do I do? Developing a competency inventory for postgraduate (residency) program directors.

BACKGROUND: Few new Residency Program Directors (PD) are formally trained for the demands and responsibilities of the leadership aspect of their role. Currently, there are no comprehensive frameworks that describe specific leadership competencies that can inform PD self-reflection or faculty development. METHODS: The authors developed a Postgraduate Program Director Competency Inventory (PPDCI) in order to frame the performance of PDs for a multisource feedback (MSF) program. The development of the PPDCI occurred in five phases which involved: development of an initial inventory, implementation of a key informant survey of national opinion leaders, execution of a validity survey with postgraduate education leaders and committee members and implementation of a further refined inventory with 17 PD and 147 raters as part of a pilot MSF program. OUTCOMES: Five distinct domains of leadership competence were identified which included: Communication and relationship management, leadership, professionalism and self-management, environmental engagement, and management skills and knowledge. The content validity of the PPDCI was endorsed by 85% of the key informants. The validity survey indicated strong endorsement of the PPDCI domains and recognition of its utility for both orientation of new PD as well as a frame for self-assessment. The pilot MSF program yielded a further refined and reduced inventory of 26 items of competence as well as recommendations for its utility. CONCLUSIONS: Use of this leadership inventory has the potential to ensure effective leadership of postgraduate programs.

Deconstructing the process of change in cognitive behavioral therapy: An alternative approach focusing on the episodic retrieval mode.

Lane et al. view the process of memory reconsolidation as a main ingredient of psychotherapeutic change. They ascertain that in cognitive behavioral therapy (CBT) high priority is given to the "semantic structure." We argue that memory-related mechanisms of change in CBT are more nuanced than the target article presents. Furthermore, we propose to partially shift the focus from the process of reconsolidation to the retrieval operations.

Is immediate adjunctive CBT more beneficial than delayed CBT in treating depression?: A Pilot Study.

Cognitive-behavioral therapy (CBT) is an efficacious first-line therapy for patients with major depressive disorder (MDD). Due to the limited accessibility of CBT, long wait lists result in delayed treatment, which may affect treatment outcomes. The goal of this pilot study was to obtain preliminary data from a randomized controlled trial to determine whether delayed CBT reduces the effectiveness of the therapy compared to immediate CBT in patients with MDD receiving pharmacotherapy. Patients were randomized to receive immediate CBT (n=18) or to begin CBT after 6 months (n=20) and received 14 weekly sessions, followed by two additional booster sessions. During the active treatment months, patients in the immediate group demonstrated reductions in scores on the Beck Depression Inventory II (BDI-II) that were similar to those in the delayed CBT group. However, when the analysis was performed using only data from patients in the delayed group who were still in a depressive episode, there was an overall greater decrease in BDI-II scores in the immediate group vs. the delayed group over the active treatment months, but not specifically at the 6-month endpoint. These findings suggest delays in depression treatment, similar to what occurs with real-world wait list times, may not have a significant impact on the effectiveness of CBT in patients who are already receiving treatment as usual. However, such delays may affect the effectiveness of CBT in those patients who remain depressed during the time delay. A larger trial is necessary to confirm these findings. (Journal of Psychiatric Practice 2015;21:107-113).

Combined treatment: impact of optimal psychotherapy and medication in bipolar disorder.

OBJECTIVES: The current study investigated the longitudinal course of symptoms in bipolar disorder among individuals receiving optimal treatment combining pharmacotherapy and psychotherapy, as well as predictors of the course of illness. METHODS: A total of 160 participants with bipolar disorder (bipolar I disorder: n = 115; bipolar II disorder: n = 45) received regular pharmacological treatment, complemented by a manualized, evidence-based psychosocial treatment - that is, cognitive behavioral therapy or psychoeducation. Participants were assessed at baseline and prospectively for 72 weeks using the Longitudinal Interval Follow-up Evaluation (LIFE) scale scores for mania/hypomania and depression, as well as comparison measures (clinicaltrials.gov identifier: NCT00188838). RESULTS: Over a 72-week period, patients spent a clear majority (about 65%) of time euthymic. Symptoms were experienced more than 50% of the time by only a quarter of the sample. Depressive symptoms strongly dominated over (hypo)manic symptoms, while subsyndromal symptoms were more common than full diagnosable episodes for both polarities. Mixed symptoms were rare, but present for a minority of participants. Individuals experienced approximately six significant mood changes per year, with a full relapse on average every 7.5 months. Participants who had fewer depressive symptoms at intake, a later age at onset, and no history of psychotic symptoms spent more weeks well over the course of the study. CONCLUSIONS: Combined pharmacological and adjunctive psychosocial treatments appeared to provide an improved course of illness compared to the results of previous studies. Efforts to further improve the course of illness beyond that provided by current optimal treatment regimens will require a substantial focus on both subsyndromal and syndromal depressive symptoms.

A framework for understanding international medical graduate challenges during transition into fellowship programs.

BACKGROUND: Previous studies have highlighted unique needs of international medical graduates (IMG) during their transition into medical training programs; however, limited data exist on IMG needs specific to fellowship training. PURPOSES: We conducted the following mixed-method study to determine IMG fellow training needs during the transition into fellowship training programs in psychiatry and surgery. METHODS: The authors conducted a mixed-methods study consisting of an online survey of IMG fellows and their supervisors in psychiatry or surgery fellowship training programs and individual interviews of IMG fellows. The survey assessed (a) fellows' and supervisors' perceptions on IMG challenges in clinical communication, health systems, and education domains and (b) past orientation initiatives. In the second phase of the study, IMG fellows were interviewed during the latter half of their fellowship training, and perceptions regarding orientation and adaptation to fellowship in Canada were assessed. Survey data were analyzed using descriptive and Mann-Whitney U statistics. Qualitative interviews were analyzed using grounded theory methodology. RESULTS: The survey response rate was 76% (35/46) and 69% (35/51) for IMG fellows and supervisors, respectively. Fellows reported the greatest difficulty with adapting to the hospital system, medical documentation, and balancing one's professional and personal life. Supervisors believed that fellows had the greatest difficulty with managing language and slang in Canada, the healthcare system, and an interprofessional team. In Phase 2, fellows generated themes of disorientation, disconnection, interprofessional team challenges, a need for IMG fellow resources, and a benefit from training in a multicultural setting. CONCLUSIONS: Our study results highlight the need for IMG specific orientation resources for fellows and supervisors. Maslow's Hierarchy of Needs may be a useful framework for understanding IMG training needs.

Psychosocial interventions for bipolar disorder and coping style modification: similar clinical outcomes, similar mechanisms?

OBJECTIVE: To investigate changes in the use of coping styles in response to early symptoms of mania in cognitive-behavioural therapy (CBT), compared with psychoeducation, for bipolar disorder. METHOD: Data were drawn from a randomized controlled trial comparing CBT and psychoeducation. A subsample of 119 participants completed the Coping Inventory for the Prodromes of Mania and symptom assessments before treatment and 72 weeks later. RESULTS: Both CBT and psychoeducation were associated with similar improvements in symptom burden. Both treatments also produced equivalent improvements in stimulation reduction and problem-directed coping styles, but no statistically significant change on the endorsement of help-seeking behaviours. A treatment interaction showed that a reduction in denial and blame was present only in the CBT treatment condition. CONCLUSIONS: CBT and psychoeducation have similar impacts on coping styles for the prodromes of mania. The exception to this is denial and blame, which is positively impacted only by CBT but which does not translate into improved outcome. Given the similar change in coping styles and mood burden, teaching patients about how to cope in adaptive ways with the symptoms of mania may be a shared mechanism of change for CBT and psychoeducation. CLINICAL TRIAL REGISTRATION NUMBER: NCT00188838.

Objectif : Rechercher les changements d'utilisation des styles d'adaptation en réponse aux premiers symptômes de manie dans la thérapie cognitivo-comportementale (TCC), comparativement à la psychoéducation, pour le trouble bipolaire. Méthode : Les données ont été tirées d'un essai randomisé contrôlé comparant la TCC avec la psychoéducation. Un sous-échantillon de 119 participants a rempli l'inventaire d'adaptation aux prodromes de manie et les évaluations de symptômes avant le traitement, et 72 semaines plus tard. Résultats : La TCC et la psychoéducation étaient associées à des améliorations semblables du fardeau des symptômes. Les deux traitements produisaient aussi des améliorations équivalentes de la réduction de stimulation et des styles d'adaptation axée sur les problèmes, mais aucun changement statistiquement significatif de l'acceptation de comportements de recherche d'aide. Une interaction des traitements a montré qu'une réduction du déni et du blâme n'était présente que dans le traitement par TCC. Conclusions : La TCC et la psychoéducation ont des effets semblables sur les styles d'adaptation pour les prodromes de la manie. Font exception le déni et le blâme, qui ne répondent positivement qu'à la TCC, ce qui ne se traduit pas par un meilleur résultat. Étant donné le changement semblable des styles d'adaptation et du fardeau de l'humeur, enseigner aux patients comment adopter des moyens de s'adapter aux symptômes de manie peut être un mécanisme de changement partagé par la TCC et la psychoéducation. Numéro d'enregistrement de l'essai clinique : NCT00188838.

Continuing education to go: capacity building in psychotherapies for front-line mental health workers in underserviced communities.

OBJECTIVE: To address the gaps between need and access, and between treatment guidelines and their implementation for mental illness, through capacity building of front-line health workers. METHODS: Following a learning needs assessment, work-based continuing education courses in evidence-supported psychotherapies were developed for front-line workers in underserviced community settings. The 5-hour courses on the fundamentals of cognitive-behavioural therapy, interpersonal psychotherapy, motivational interviewing, and dialectical behaviour therapy each included videotaped captioned simulations, interactive lesson plans, and clinical practice behaviour reminders. Two courses, sequentially offered in 7 underserviced settings, were subjected to a mixed methods evaluation. Ninety-three nonmedical front-line workers enrolled in the program. Repeated measures analysis of variance was used to assess pre- and postintervention changes in knowledge and self-efficacy. Qualitative data from 5 semistructured focus groups with 25 participants were also analyzed. RESULTS: Significant pre- and postintervention changes in knowledge (P < 0.001) were found in course completers. Counselling self-efficacy improved in participants who took the first course offered (P = 0.001). Dropouts were much less frequent in peer-led, small-group learning than in a self-directed format. Qualitative analysis revealed improved confidence, morale, self-reported practice behaviour changes, and increased comfort in working with difficult clients. CONCLUSION: This work-based, multimodal, interactive, interprofessional curriculum for knowledge translation of psychotherapeutic techniques is feasible and helpful. A peer-led group format is preferred over self-directed learning. Its application can build capacity of front-line health workers in helping patients who suffer from common mental disorders.

Objectif : Aborder l'écart entre les besoins et l'accès, et entre les lignes directrices de traitement et leur mise en œuvre pour la maladie mentale, par la création de capacité des travailleurs de première ligne de la santé. Méthodes : À la suite d'une évaluation des besoins d'apprentissage, des cours de formation continue en milieu de travail sur les psychothérapies fondées sur des données probantes ont été mis au point à l'intention des travailleurs de première ligne dans des milieux communautaires sous-desservis. Les cours de 5 heures sur les fondements de la thérapie cognitivo-comportementale, la psychothérapie interpersonnelle, la technique d'entrevue motivationnelle, et la thérapie comportementale dialectique comportaient tous des simulations enregistrées sur vidéo, des plans de leçon interactifs, et des rappels de comportement en pratique clinique. Deux cours, offerts en ordre séquentiel dans 7 milieux sous-desservis, ont été soumis à une évaluation de méthodes mixtes. Quatre-vingt-treize travailleurs de première ligne non médicaux se sont inscrits au programme. Une analyse de variance des mesures répétées a servi à évaluer les changements des connaissances et de l'auto-efficacité avant et après l'intervention. Les données qualitatives de 5 groupes de discussion semi-structurés de 25 participants ont également été analysées. Résultats : Des changements significatifs des connaissances (P < 0,001) avant et après l'intervention ont été observés chez ceux qui ont terminé le cours. L'auto-efficacité en counseling s'est améliorée chez les participants qui ont suivi le premier cours offert (P = 0,001). Les décrocheurs étaient beaucoup moins fréquents dans les petits groupes d'apprentissage menés par les pairs que dans le format autodirigé. L'analyse qualitative a révélé une confiance améliorée, un meilleur moral, des changements du comportement dans la pratique auto-déclaré, et une plus grande assurance de travailler avec des clients difficiles. Conclusion : Ce programme d'études en milieu de travail, multimodal, interactif, interprofessionnel pour la transmission des connaissances en techniques psychothérapeutiques est faisable et utile. Le format du groupe mené par les pairs est préféré à l'apprentissage autodirigé. Son application peut renforcer la capacité des travailleurs de la santé de première ligne d'aider les patients qui souffrent de troubles mentaux communs.

Evaluating psychiatry residents as physician-managers: development of an assessment tool.

OBJECTIVES: With the emergence of physician-manager (PM) curricula in medical education, more effective assessment tools are needed to evaluate psychiatry trainees in this role. The aim of this study was to determine psychiatry residents', program directors', and PM educators' perceptions about PM role-assessment. METHODS: Psychiatry residents at two Canadian programs were given a survey on PM assessment and the use of portfolios to assess PM competency. Qualitative interviews of Canadian psychiatry educators and program directors were used to determine faculty perceptions on PM assessment. Authors analyzed survey data with descriptive statistics, and qualitative interviews were analyzed using a grounded theory approach. RESULTS: Nearly 55% of psychiatry residents responded to the survey; 47% of residents did not want to change the way they were assessed by the PM role. Residents identified an array of assessment methods for each of the specific PM domains. Educator interview themes included supervisor and resident barriers to assessment, the need for new PM assessment approaches integrating multiple assessment methods, and a role for the use of portfolios if sufficient infrastructure was available. CONCLUSION: The data supported a preference for a multimodal approach to assessment of the PM role. Future research should examine the implementation of the proposed PM assessment tool.

Preparing international medical graduates for psychiatry residency: a multi-site needs assessment.

OBJECTIVE: Despite the growing number of international medical graduates (IMGs) training in medicine in Canada and the United States, IMG-specific challenges early in psychiatry residency have not been fully explored. Therefore, the authors conducted a needs-assessment survey to determine the needs of IMGs transitioning into psychiatry residency. METHOD: Using a 15-item online questionnaire, authors conducted a needs-assessment of IMG residents in five Canadian psychiatry residency programs. The survey examined IMGs' perceived difficulties with the transition into psychiatry residency, educational needs, and demographic data. Data were analyzed with descriptive statistics and Mann-Whitney tests. RESULTS: IMGs identified the following difficulties with their transition into residency: understanding the healthcare system, medical documentation, and evidence-based medicine/mental health. Language barriers and social isolation were significant factors affecting the transition into residency for residents who did not speak English as their first language. Residents who lived in Canada 12 months or less had greater perceived difficulties in psychotherapy knowledge and adapting to the Canadian healthcare system; 88% of IMGs reported having little-or-no IMG-specific preparation for psychiatry residency from their psychiatry program; however, 69% reported that they would use IMG resources if offered; 63% felt that faculty in their program should undergo training to assist with IMG transition. CONCLUSION: Several perceived challenges, needs, and gaps in training were reported by IMGs in Canadian psychiatry residency programs. The results of this survey will be used to inform future curriculum development to facilitate IMG transition into psychiatry postgraduate training programs.

A randomized controlled trial of psychoeducation or cognitive-behavioral therapy in bipolar disorder: a Canadian Network for Mood and Anxiety treatments (CANMAT) study [CME].

OBJECTIVE: Bipolar disorder is insufficiently controlled by medication, so several adjunctive psychosocial interventions have been tested. Few studies have compared these psychosocial treatments, all of which are lengthy, expensive, and difficult to disseminate. We compared the relative effectiveness of a brief psychoeducation group intervention to a more comprehensive and longer individual cognitive-behavioral therapy intervention, measuring longitudinal outcome in mood burden in bipolar disorder. METHOD: This single-blind randomized controlled trial was conducted between June 2002 and September 2006. A total of 204 participants (ages 18-64 years) with DSM-IV bipolar disorder type I or II participated from 4 Canadian academic centers. Subjects were recruited via advertisements or physician referral when well or minimally symptomatic, with few exclusionary criteria to enhance generalizability. Participants were assigned to receive either 20 individual sessions of cognitive-behavioral therapy or 6 sessions of group psychoeducation. The primary outcome of symptom course and morbidity was assessed prospectively over 72 weeks using the Longitudinal Interval Follow-up Evaluation, which yields depression and mania symptom burden scores for each week. RESULTS: Both treatments had similar outcomes with respect to reduction of symptom burden and the likelihood of relapse. Eight percent of subjects dropped out prior to receiving psychoeducation, while 64% were treatment completers; rates were similar for cognitive-behavioral therapy (6% and 66%, respectively). Psychoeducation cost $180 per subject compared to cognitive-behavioral therapy at $1,200 per subject. CONCLUSIONS: Despite longer treatment duration and individualized treatment, cognitive-behavioral therapy did not show a significantly greater clinical benefit compared to group psychoeducation. Psychoeducation is less expensive to provide and requires less clinician training to deliver, suggesting its comparative attractiveness. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00188838.