Association of Early Treatment With Chronicity and Hazard of Hospitalization After New Adjustment Disorder.

OBJECTIVE: This study aimed to examine the effect of early treatment with psychotherapy or psychoactive medications on later hospitalizations for patients with a new diagnosis of adjustment disorder. METHODS: Commercial claims data from Truven Health MarketScan were used. Patient-level propensity score matching was performed, and the authors fit an inverse probability of treatment weighting to a Cox proportional hazard model. RESULTS: Early receipt of psychoactive medication instead of psychotherapy was associated with an increased hazard of later psychiatric hospitalization (hazard ratio [HR]=2.61, 95% confidence interval [CI]=2.07-3.28) and overall hospitalization (HR=1.12, 95% CI=1.04-1.21). Specifically, benzodiazepines were associated with increased hazard of later psychiatric hospitalization (HR=1.59, 95% CI=1.02-2.51), which did not differ from medications overall. In contrast, early receipt of psychotherapy was associated with a small decrease in the hazard of later psychiatric hospitalization (HR=0.85, 95 % CI=0.73-0.99) but had no effect on overall hospitalizations. CONCLUSIONS: Early medication treatment for adjustment disorder was associated with greater overall and psychiatric hospitalization compared with no early medication treatment. This study suggests that an observed provider preference to use medications to treat patients who have comorbid physical illness may have deleterious long-term effects.

Binge-Eating Disorder: An Interactive Self-Learning Module.

INTRODUCTION: This resource is a web-based and self-contained self-learning module (SLM) on binge-eating disorder (BED) that runs utilizing Articulate software. Certain skills and knowledge are required to both interview and manage patients diagnosed with the disorder. Because BED may be encountered by medical students, this module can help inform the learning process. METHODS: Software was utilized to develop an SLM for third-year medical students utilizing video clips demonstrating the evolution of a clinical BED case from presentation to follow-up over 10-12 weeks. The focus is on differential diagnosis and management, with intermittent self-assessment quizzes and other evidence-based literature for further study. The module follows the case of Ms. Melanie May, who has been referred for help to lose weight. Further assessment reveals that she has BED. By having her needs therapeutically attended to, she receives help through focused cognitive behavioral therapy, the use of food log monitoring, and medications. RESULTS: This SLM on BED has been implemented at the University of Toronto as an optional component of the psychiatry clerkship over the 2015/2016 academic year. Written and verbal feedback from faculty (n = 5) and students (n = 5) has been overwhelmingly positive. DISCUSSION: This SLM is intended as a clinical application exercise for third-year medical students who may not encounter patients with BED or who want to increase their clinical understanding of how to help patients who present with obesity and binge-eating complaints.

Assessing competencies during education in psychiatry.

The utilization of competencies in medical education is relatively recent. In 1999 the United States Accreditation Council for Graduate Medical Education (ACGME) established six main competencies. Since then, the American Board of Psychiatry and Neurology have approved a specific list of competencies for their specialities in each of the ACGME's core competency areas. Assessment of competencies in both medical students and residents can be achieved through such methods as structured case discussion, direct observation, simulation, standardized patients, and 360-degree assessments, etc. Each assessment methodology has specific applications in the discipline of psychiatry. This paper reviews the different methods for assessing competencies with specific examples in psychiatric education. It is not intended as a comprehensive review of all assessment methods, but to provide examples and strategies to guide psychiatric educators in their practice. Students and residents were intentionally separated because there are differences in the teaching goals and objectives, and thus in the assessment purposes and design. Students are general, undifferentiated physicians-in-training who need to learn about psychiatric nosology, examinations, and treatment. Residents are mental health professionals who need more in-depth supervision in order to hone skills in all the specialized areas that arise in psychiatric practices, making supervision a vital part of residency programs.

An approach to the patient with organ failure: transplantation and end-of-life treatment decisions.

Organ transplantation offers an opportunity for extended survival and enhanced quality of life to patients with end-stage organ disease. Significant challenges are associated with both pre- and post-transplantation care, however, that require awareness of psychiatric issues in this patient population. Ventricular assist devices have added another dimension to patient care and to quality-of-life considerations. Unfortunately, effective incorporation of palliative care and end-of-life discussions is frequently overlooked during caretaking of these patients.

Psychiatric issues in solid organ transplantation.

The identification and treatment of psychiatric comorbidity in patients undergoing solid organ transplantation present a unique opportunity for psychiatric involvement in the care of medically complex patients. The burden of psychiatric illness in patients awaiting transplant and following transplant is significant and associated with potential morbidity and mortality. Possibilities for psychiatric liaison with our colleagues in transplant medicine and surgery start with the comprehensive psychiatric evaluation that is often performed with potential organ recipients and donors. The vital role of the psychiatrist continues following transplantation, as adjustment is often a stressful experience with associated psychiatric comorbidity. The treatment of psychiatric illness in patients following transplantation requires an understanding of the immunosuppressant medications that patients may be taking, coupled with an awareness of the associated risks of adverse effects and drug-drug interactions.

Psychiatric aspects of epilepsy.

Patients who have epilepsy face many challenges resulting from their illness and have frequent psychiatric comorbidities. Recognition of these disorders is increasing and is having a positive impact on patients' quality of life. Recent recommendations about a new classification system for psychiatric disorders related specifically to epilepsy and based on the relationship of symptoms to seizures, antiepileptic medications, and EEG changes should further research and treatment. Especially insofar psychiatric syndromes specific to epilepsy can be identified, correlation of clinical phenomena with relatively well-understood pathophysiology in epilepsy will allow advances in the understanding of psychiatric illness. This progress should move the treatment of patients who have epilepsy toward a comprehensive biopsychosocial model that focuses on the whole person rather than simply on the disease process.