Dialog Across Cultures: Therapy for Diverse Families.

Child and adolescent psychiatrists (CAPs) work at the intersections of families, cultures, and systems, which affect engagement in care, assessment, and treatment planning. There are several practical strategies that CAPs can apply to practice cultural humility, to join with families, to facilitate difficult conversations and to work through misalignment. Culturally inclusive family-based care can promote greater understanding and lead to stronger outcomes with families as well as help mitigate mental health impact of structural racism and social inequities.

Anorexia nervosa, conduct disorder, and the juvenile justice system: a case of applying traditional treatment modalities in a non-traditional setting.

BACKGROUND: Anorexia Nervosa is highly comorbid with depressive, anxiety, and obsessive-compulsive spectrum disorders. However, it has not previously been reported as comorbid with antisocial personality traits, except when substance use disorder is also identified. We present an unusual case of a patient with resistant anorexia nervosa and comorbid conduct disorder. This case was also unique in that the juvenile justice system was involved during treatment. CASE PRESENTATION: A 13-year-old female was admitted to our pediatric hospital for the treatment of anorexia nervosa. She had a history of violent behaviors toward family members, often jeopardizing her care. During hospitalization, she physically attacked a physician on her care team shortly before she transitioned to an eating disorders treatment program. She was diagnosed with conduct disorder, and following discharge, she attacked her father in a premeditated act. This led to her entry into the juvenile justice system. While under the custody of the juvenile justice system, she was readmitted to our hospital for further treatment of anorexia nervosa. Our treatment strategy included psychotropics, positive reinforcement, close interdisciplinary coordination among the various hospital teams, and the juvenile justice system. Following discharge from her second hospitalization back to the juvenile detention system, our patient maintained a healthy weight and appeared to show improvements in the cognitive distortions related to her eating disorder. CONCLUSIONS: To our knowledge, this is the first reported successful treatment of an individual with resistant anorexia nervosa and conduct disorder. It was likely a combination of weight gain, psychotropic medications, and the structured milieu provided by the juvenile justice system that led to the effective treatment of our patient. This case illustrates that a non-traditional healthcare setting can be an asset to treatment through persistence and close collaboration across institutions.

Adaptations Made to Pediatric Consultation-Liaison Psychiatry Service Delivery During the Early Months of the COVID-19 Pandemic: A North American Multisite Survey.

BACKGROUND: The COVID-19 pandemic led to rapid changes in clinical service delivery across hospital systems nationally. Local realities and resources were key driving factors impacting workflow changes, including for pediatric consultation-liaison psychiatry service (PCLPS) providers. OBJECTIVE: This study aims to describe the early changes implemented by 22 PCLPSs from the United States and Canada during the COVID-19 pandemic. Understanding similarities and differences in adaptations made to PCLPS care delivery can inform best practices and future models of care. METHODS: A 20-point survey relating to PCLPS changes during the COVID-19 pandemic was sent to professional listservs. Baseline hospital demographics, hospital and PCLPS workflow changes, and PCLPS experience were collected from March 20 to April 28, 2020, and from August 18 to September 10, 2020. Qualitative data were collected from responding sites. An exploratory thematic analysis approach was used to analyze the qualitative data that were not dependent on predetermined coding themes. Descriptive statistics were calculated using Microsoft Excel. RESULTS: Twenty-two academic hospitals in the United States and Canada responded to the survey, with an average of 303 beds/hospital. Most respondents (18/22) were children's hospitals. Despite differences in regional impact of COVID-19 and resource availability, there was significant overlap in respondent experiences. Restricted visitation to one caregiver, use of virtual rounding, ongoing trainee involvement, and an overall low number of COVID-positive pediatric patients were common. While there was variability in PCLPS care delivery occurring virtually versus in person, all respondents maintained some level of on-site presence. Technological limitations and pediatric provider preference led to increased on-site presence. CONCLUSIONS: To our knowledge, this is the first multicenter study exploring pandemic-related PCLPS changes in North America. Findings of this study demonstrate that PCLPSs rapidly adapted to COVID-19 realities. Common themes emerged that may serve as a model for future practice. However, important gaps in understanding their effectiveness and acceptability need to be addressed. This multisite survey highlights the importance of establishing consensus through national professional organizations to inform provider and hospital practices.

Gender distribution in psychiatry journals' editorial boards worldwide.

Gender disparity has been documented in advanced doctoral degrees, research, and academic positions, and therefore, it can logically be deduced that the gender disparity would be found in journals' editorial boards. In this study, we sought to determine the gender distribution in editorial boards of psychiatry journals worldwide. We also studied the academic achievements of editorial board members by comparing professional background, education level, and research productivity indices. We analyzed the gender of editorial members of 119 psychiatry journals from Clarivate Analytics' Journal Citation Reports. Our data included 8423 editorial board members from which we randomly selected 10% editorial board members to represent the full sample for further analyses. Overall, women represented 30.4% of editorial board and approximately 30% in each category: (1) Editor-in-chief/deputies, (2) Associate/section editors, (3) Editorial board*, and (4) Advisory board. The majority (65%) of men were M.D. psychiatrists, and women (58%) were Ph.D. psychologists. Women in editorial leadership positions (Category 1 & 2) were correlated with fewer women in editorial or advisory boards. Women had half the mean number of publications than men while serving journals with approximately the same mean impact factor. Our study results show that, besides gender disparity, gender bias does not exist in the psychiatry journal editorial boards. Given the implication of the editorial board position on science, academic advancement, and networking, this disparity remains detrimental to achieving equity, diversity, and inclusion in academic psychiatry.

Suicide Risk Screening in Pediatric Hospitals: Clinical Pathways to Address a Global Health Crisis.

BACKGROUND: Youth suicide is on the rise worldwide. Most suicide decedents received healthcare services in the year before killing themselves. Standardized workflows for suicide risk screening in pediatric hospitals using validated tools can help with timely and appropriate intervention, while attending to The Joint Commission Sentinel Event Alert 56. OBJECTIVE: Here we describe the first attempt to generate clinical pathways for patients presenting to pediatric emergency departments (EDs) and inpatient medical settings. METHODS: The workgroup reviewed available evidence and generated a series of steps to be taken to feasibly screen medical patients presenting to hospitals. When evidence was limited, expert consensus was used. A standardized, iterative approach was utilized to create clinical pathways. Stakeholders reviewed initial drafts. Feedback was incorporated into the final pathway. RESULTS: Clinical pathways were created for suicide risk screening in pediatric EDs and inpatient medical/surgical units. The pathway outlines a 3-tiered screening process utilizing the Ask Suicide-Screening Questions for initial screening, followed by a brief suicide safety assessment to determine if a full suicide risk assessment is warranted. This essential step helps conserve resources and decide upon appropriate interventions for each patient who screens positive. Detailed implementation guidelines along with scripts for provider training are included. CONCLUSION: Youth suicide is a significant public health problem. Clinical pathways can empower hospital systems by providing a guide for feasible and effective suicide risk-screening implementation by using validated tools to identify patients at risk and apply appropriate interventions for those who screen positive. Outcomes assessment is essential to inform future iterations.

Neuroimaging in Psychiatric Disorders: A Bibliometric Analysis of the 100 Most Highly Cited Articles.

BACKGROUND AND PURPOSE: Extensive research has been conducted to find neuroimaging biomarkers for psychiatric disorders. This study aimed at identifying trends of the 100 most highly cited articles on neuroimaging in primary psychiatric disorders. METHODS: The most highly cited original research articles were identified and analyzed, following searches of MEDLINE and Web of Science All Databases. RESULTS: The top 100 articles ranked by yearly citation (from 137.5 to 31.1) were published between 1989 and 2017. Depressive disorders (30 articles), schizophrenia spectrum and other psychotic disorders (27), autism spectrum disorder (17), substance-related and addictive disorders (7), and post-traumatic stress disorder (7) were among the most studied conditions. Functional magnetic resonance imaging (42), structural magnetic resonance imaging (30), and positron emission tomography (22) were the most utilized neuroimaging modalities. While 85 articles investigated the pathophysiology of psychiatric disorders (including 7 focusing on developmental changes and 1 on genetic susceptibility), 15 articles studied the impact of treatment, including antidepressants (6), deep brain stimulation (4), antipsychotics (3), behavior therapy (3), and exercise (1). The analysis also identified the most contributing authors, countries (the United States: 71 articles, the United Kingdom: 8, Canada: 5, and China: 5), and journals (JAMA Psychiatry: 20 articles and Biological Psychiatry: 17). Ninety-eight studies were prospective, and two were retrospective. The sample size ranged from 3 to 1,188 (median: 21). CONCLUSIONS: Our study identified intellectual milestones in the utility of neuroimaging in investigating primary psychiatric disorders. The historic trends could help guide future research in this field.

Cultural Considerations for Autonomy and Medical Adherence in a Young Palestinian American Muslim Female With Spina Bifida: A Longitudinal Case Study in a Research Context.

This case study examines the unique presentation of a young Palestinian-American Muslim female, who is a part of an ongoing longitudinal study examining family and peer relationships, psychological adjustment, and neuropsychological functioning in youth with spina bifida. Throughout ten years of data collection, Palestinian-Arab culture and Islamic faith have consistently emerged as important factors that can be considered when interpreting this participant's general level of autonomy, medical autonomy, medical adherence, and psychological adjustment. This case study examines important aspects of adaptive and independent functioning for youth with spina bifida and how this family's culture interacts with these different domains of functioning. Moreover, it explores potential conflicts between an Arab collectivist family structure and Western biomedical ethics and suggests how clinicians might navigate these conflicts and bolster culturally-rooted strengths of families and patients from non-Western backgrounds.

A multidisciplinary approach to the treatment of anti-NMDA-receptor antibody encephalitis: a case and review of the literature.

Anti-NMDAR (N-methyl-d-aspartate receptor) encephalitis is a novel autoimmune and paraneoplastic disease often presenting as acute psychosis. Few studies exist in the psychiatric literature on neuroimmunity and behavioral management. This article reviews the epidemiology, diagnosis, pathophysiology, and management of this disease from a neuropsychiatric perspective. Patients have potential for near-complete recovery with early diagnosis and intervention. In addition to immune-suppression and tumor removal, electroconvulsive therapy may be an important tool in treatment of the underlying process in cases developing life-threatening catatonia. Psychiatrists should be familiar with treatment options, since they may be consulted within the context of a multispecialty team.

Primary language and cultural background as factors in resident burnout in medical specialties: a study in a bilingual US city.

OBJECTIVE: The aim of this study was to identify the degree of burnout among resident physicians enrolled in seven postgraduate training programs at Texas Tech University Health Sciences Center (TTUHSC), Paul L. Foster School of Medicine, El Paso, Texas, as it related to residents' age, gender, marital status, number of hours worked per week, primary language, race/ethnicity, and cultural background. METHOD: : The Maslach Burnout Inventory Human Service Survey (MBI) was administered to measure the level of burnout according to the prevalence of emotional exhaustion (EE), depersonalization (DP), and reduced personal accomplishment (PA). RESULTS: : Eighty-one percent of the residents at TTUHSC participated in the study. Residents raised in the United States or Canada comprised 28% and 35% of the study, and all reported English as their primary language. The EE scale was significant for obstetrics/gynecology (OB/GYN) residents (prevalence odds ratio [POR] = 13.55, P = 0.02) and psychiatry (PSY) residents (POR = 6.50, P = 0.03). Emergency medicine (EM) residents (POR = 23.35, P = 0.002), OB/GYN (POR = 10.89, P = 0.02), and general surgery (GS) (POR = 6.24, P = 0.03) residents had high DP. Internal medicine (IM) residents (primarily Spanish-speaking) reported significantly low EE (POR = 0.22, P = 0.03) and PA (POR = 0.09, P = 0.001) scores. Residents from the United States or Canada who reported English as their primary language and noted their race as white, had high EE (POR = 3.06, P = 0.03; POR = 5.61, P = 0.0001; POR = 2.91, P = 0.004), DP (POR = 3.19, P = 0.02; POR = 8.34, P < or = 0.0001; POR = 4.70, P < or = 0.0001) and PA (POR = 2.61, P = 0.02; POR = 2.35, P = 0.05, POR 0.29, P = 0.3) scores. CONCLUSION: Using valid measures, this pilot study identified a statistically significant relationship between burnout and residents' race/ethnicity, primary language, and cultural background. Larger studies with similar focus would be necessary to generalize these findings. At-risk residents in bilingual locations should be provided with cultural awareness workshops, language assistance programs, as well as senior resident and faculty mentors.

The health care matrix formulation: a tool for competency assessment in psychiatry residency training.

OBJECTIVE: To assert the importance of the use of the healthcare matrix formulation for competency assessment in psychiatry residency training. METHODS: We present a case from our inpatient psychiatric facility and format it in the form of the healthcare matrix, which was developed at Vanderbilt University incorporating the Institute of Medicine 'aims' and the Accreditation Council for Graduate Medical Education 'core competencies'. We also analyze the healthcare matrix and elucidate its use in clinical practice. RESULTS: The healthcare matrix provides us with a practical tool to analyze any complex episode of patient care, like the one in our psychiatric setting, and allows us to learn from the shortcomings in order to improve. CONCLUSION: The optimal utilization of this tool in the competency assessment of psychiatry residents has an enormous practical implication by transforming the case and morbidity and mortality conferences into a well-structured learning and improvement format.

Risperidone-induced polydipsia and polyphagia associated with galactorrhea, abdominal pain, and rapid weight gain in an adolescent Hispanic female.

A 15-year-old Hispanic female was started on risperidone for new-onset psychosis. The patient responded well to the gradual dose increase but developed rapid weight gain secondary to polydipsia and polyphagia. She also began complaining of nipple discharge and griping abdominal pain on the left lower quadrant by the third week of treatment. Her prolactin level escalated to three times normal with a weight gain of 12 pounds in 16 days. Risperidone was switched to another antipsychotic. Her prolactin level then dropped to a normal level within 7 days and she lost 7 pounds in the next 2 weeks. Her abdominal pain, galactorrhea, polydipsia, and polyphagia subsided within the first few days of the cessation of risperdione.