A 10-Year Follow-up Survey of Psychiatry Resident Education in Consultation-Liaison Psychiatry.

BACKGROUND: In 2010, the Academy of Consultation-Liaison (then Academy of Psychosomatic Medicine) surveyed US residency programs to understand training in consultation-liaison (CL) psychiatry, leading to recommendations in 2014. Since then, residency training in CL has evolved in the context of competing training demands, increased prioritization of electives, and reactions to coronavirus 2019. OBJECTIVE: To determine the current state of residency training in CL across the United States, including the structure of core and elective resident rotations in CL, attending physician staffing, presence of fellows and other trainees, didactic curriculum, and impact of coronavirus 2019. METHODS: Members of the Academy of Consultation-Liaison Residency Education Subcommittee designed and piloted an 81-question survey tool that was sent to program directors of 269 US general psychiatry training programs for voluntary completion. RESULTS: One hundred three of 269 programs responded to the survey, yielding a response rate of 38.3%. Responding programs were larger and more likely to have a CL fellowship than nonresponding programs. Of the 103 responding programs, 82.5% have more than the minimally required time on CL, with 46.6% reporting an increase in total CL time in the past decade. Since 2010, 18.4% of responding programs changed the placement of the CL rotation, with 43.7% now adherent to the 2014 Academy of Psychosomatic Medicine recommendation to include core CL training in the second half of residency. Thirty-five percent of responding programs require residents to rotate on more than 1 CL service, and 19.4% have a required outpatient CL component. Faculty full-time equivalent varies widely. Of all services included, 33.8% report that all CL faculty are board-certified in CL psychiatry, whereas 18.7% have no board-certified faculty. Of the 103 responding programs, 36.9% offer a CL fellowship, but 31.1% report no residency graduates pursuing CL fellowships in the past 5 years. Of the included programs, 77.7% have a formal CL curriculum for residents, with 34.0% reporting a separate didactic series during the CL rotation. CONCLUSIONS: Among the responding programs, the amount of time spent on core CL rotations has increased in the past decade, but programs have also shifted CL training earlier in the course of residency. Residency programs are increasingly challenged to provide an optimal CL experience, and updated guidance from Academy of Consultation-Liaison may be appreciated.

Indirect Effects of Racial Discrimination on Health Outcomes Through Prefrontal Cortical White Matter Integrity.

BACKGROUND: Racial discrimination is consistently associated with adverse health outcomes and has been linked to structural decrements in brain white matter. However, it is unclear whether discrimination-related neuroplastic changes could indirectly affect health outcomes. Our goal was to evaluate indirect associations of racial discrimination on health outcomes through white matter microstructure in a sample of trauma-exposed Black women. METHODS: A trauma study in an urban hospital setting recruited 79 Black women who received a history and physical examination to assess medical disorders (compiled into a summed total of disorder types). Participants reported on experiences of racial discrimination and underwent diffusion tensor imaging; fractional anisotropy values were extracted from white matter pathways previously linked to racial discrimination (corpus callosum, including the body and genu; anterior cingulum bundle; and superior longitudinal fasciculus) and entered into mediational models. RESULTS: Indirect effects of racial discrimination on medical disorders through left anterior cingulum bundle fractional anisotropy were significant (ß = 0.07, SE = 0.04, 95% CI [0.003, 0.14]) after accounting for trauma and economic disadvantage. Indirect effects of racial discrimination on medical disorders through corpus callosum genu fractional anisotropy were also significant (ß = 0.08, SE = 0.04, 95% CI [0.01, 0.16]). CONCLUSIONS: Racial discrimination may increase risk for medical disorders via neuroplastic effects on microstructural integrity of stress-sensitive prefrontal white matter tracts. Racial discrimination-related changes in these tracts may affect health behaviors, which, in turn, influence vulnerability for medical disorders. These data highlight the connections between racial discrimination, prefrontal white matter connections, and incidence of medical disorders in Black Americans.

Making Family-Centered Care for Adults in the ICU a Reality.

Despite the value of family-centered care (FCC) in intensive care units (ICUs), this approach is rarely a reality in this context. This article aims to increase the likelihood that ICU-based care incorporates best practices for FCC. Consistent with this goal, this article begins by overviewing FCC and its merits and challenges in ICUs. It then offers a systemic framework for conceptualizing FCC in this challenging environment, as such a model can help guide the implementation of this invaluable approach. This systemic framework combined with previous guidelines for FCC in the ICU are used to inform the series of recommended best practices for FCC in the ICU that balance the needs and realities of patients, families, and the interprofessional healthcare team. These best practices reflect an integration of the existing literature and previously published guidelines as well as our experiences as healthcare providers, family members, and patients. We encourage healthcare leaders and interprofessional ICU healthcare teams to adopt these best practices and modify them for the specific healthcare needs of the patients they serve and their families.

Heart rate variability and HbA1c predict plasma interleukin-6 response to psychosocial stress challenge in trauma-exposed women with type 2 diabetes.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is a major public health problem in the United States. Although cardiovascular autonomic functioning, blood glucose control, and inflammation are known to play a role in T2DM, the interaction between these variables remains largely unexplored, particularly in the context of stress. To address this gap, we examined the relationship between these variables in a sample that is uniquely vulnerable to the health consequences of T2DM. METHODS: Participants were 37 trauma-exposed Black women with a diagnosis of T2DM. High frequency heart rate variability (HF-HRV), blood glucose control (HbA1c), and a stressor-evoked biomarker of inflammation (interleukin 6; IL-6) were obtained as part of a larger study of the genetic risk factors for and consequences of trauma exposure. RESULTS: The interaction of HbA1c and HF-HRV was significantly associated with IL-6 response calculated as area under the curve with respect to ground. Post-hoc simple slopes analyses revealed HbA1c, rather than HF-HRV, as the moderator in this association such that higher HF-HRV conferred higher circulating levels of IL-6 only in the presence of lower HbA1c, (ߠ​= â€‹0.60, t â€‹= â€‹3.51, p â€‹= â€‹.001). CONCLUSIONS: Cardiovascular autonomic functioning and blood glucose control were significantly associated with stressor-evoked IL-6 responses when controlling for BMI and age. Moreover, the association between cardiovascular autonomic functioning and inflammation varied at different levels of HbA1c. This highlights the possibility that individuals with trauma exposure and T2DM may benefit from stratification by HbA1c levels for research analysis and treatment decision making.

Integrating Diversity, Equity, and Inclusion Into an Academic Department of Psychiatry and Behavioral Sciences.

This article highlights one department's efforts to bolster diversity, equity, and inclusion as an exemplar for other academic departments. It offers an approach for building an infrastructure and leadership group and details accomplishments associated with strategic plan priorities related to visibility, values, stakeholder education, recruitment, retention, promotion, and community engagement. It also delineates challenges encountered in transforming a departmental culture to one that is more diverse, equitable, and inclusive and strategies for overcoming these challenges. Finally, it discusses next steps and recommendations for other academic departments.

Emotion dysregulation and dissociation contribute to decreased heart rate variability to an acute psychosocial stressor in trauma-exposed Black women.

Reduced heart rate variability (HRV) in response to stress is a biomarker of emotion dysregulation (ED) and is related to posttraumatic stress disorder (PTSD), yet less is known about its role with dissociation in trauma-exposed adults. The goals of the current study were to examine unique patterns of associations between ED, dissociation, and PTSD with HRV at 15, 30, and 45 min (T1, T2, T3) following an acute psychosocial stressor task in a sample of 49 trauma-exposed, urban-dwelling Black women. Associations with baseline psychophysiology measures were also examined. ED and dissociation were assessed using self-report; PTSD was determined using a semi-structured interview. Heart rate (HR) and HRV, indexed with low frequency/high frequency (LF/HF) ratio and respiratory sinus arrhythmia (RSA), were measured with electrocardiogram recordings. ED and dissociation were positively correlated with LF/HF ratio at T3 (p < .05). There were no significant differences between individuals with PTSD versus those without PTSD in HR or HRV following acute stressor; PTSD diagnosis was related to higher HR at baseline. Latent growth modeling revealed that ED was associated with higher LF/HF ratio directly following acute stressor, while dissociation was associated with increase in LF/HF ratio over time. These findings demonstrate that ED is related to higher sympathetic reactivity for a prolonged period of time following stress exposure, while dissociation shows a delayed association with LF/HF ratio, suggesting a distinct impaired parasympathetic activation pattern exists for dissociation.

Trauma exposure and stress-related disorders in a large, urban, predominantly African-American, female sample.

The current study investigated the relationship between trauma exposure and psychopathology in a sample of predominately African-American women of low socioeconomic status (SES). Women (N = 7430) were recruited from medical clinics at two large public hospitals in Atlanta, GA, from 2005 to 2017. Women were assessed for sociodemographics, life-course trauma burden, posttraumatic stress disorder (PTSD), and major depressive disorder (MDD) utilizing self-report and structured clinical interview assessments. The effects of trauma exposure on current and lifetime PTSD and MDD were examined. Ninety-one percent of women reported trauma exposure, 83% reported a monthly household income of less than $2000, and 41% reported a history of arrest. Regarding psychiatric diagnoses, 30.8% met the criteria for probable MDD, and 32.3% met the criteria for probable PTSD. History of childhood abuse and total lifetime trauma significantly increased PTSD and depressive symptoms with additional incremental trauma exposure. PTSD and depressive symptom scores (95% CI) increased from 5.5 (5.0-6.1) and 8.4 (7.9-9.0) in the no trauma group to 20.8 (20.1-21.5) and 20.4 (19.7-21.2), respectively, in those exposed to four or more types of trauma. These results show high rates of adult and childhood trauma exposure, PTSD, MDD, and an additive effect of lifetime trauma exposure on the development of PTSD and MDD in a sample of low SES African-American women. These findings bring light to the high psychiatric symptom burden in this population and call for increased availability of interventions to address symptoms as well as policies aimed at reducing trauma exposure across the lifespan.

The Educational Value of Outpatient Consultation-Liaison Rotations: A White Paper From the Academy of Consultation-Liaison Psychiatry Residency Education Subcommittee.

BACKGROUND: As mental health services in outpatient medical clinics expand, psychiatrists must be trained to practice in these settings. OBJECTIVES: The Academy of Consultation-Liaison Psychiatry residency education subcommittee convened a writing group with the goal of summarizing the current evidence about outpatient consultation-liaison psychiatry (CLP) training and providing a framework for CLP educators who are interested in developing outpatient CLP rotations within their programs. METHOD: MEDLINE (via PubMed), Embase, and PsycINFO (via OVID) were reviewed each from inception to December 2019, for psychiatric CLP services in ambulatory settings that involved residents or fellows. The CLP education guidelines were reviewed for recommendations relevant to outpatient CLP. We also searched MedEd portal for published curriculums relevant to CLP. The group held 2 conferences to reach consensus about recommendations in setting up outpatient CLP rotations. RESULTS: Seventeen articles, 3 Academy of Consultation-Liaison Psychiatry-supported guidelines, and 8 online didactic resources were identified as directly reporting on the organization and/or impact of an outpatient CLP rotation. These manuscripts indicated that residents found outpatient CLP rotations effective and relevant to their future careers. However, the literature provided few recommendations for establishing formal outpatient CLP training experiences. CONCLUSIONS: Outpatient CLP rotations offer multiple benefits for trainees, including exposure to specific clinical scenarios and therapeutic interventions applicable only in the outpatient setting, increased continuity of care, and the unique experience of providing liaison and education to non-mental health providers. The article outlines recommendations and examples for developing outpatient CLP rotations which CLP educators can incorporate in their programs.

Collaborative patient- and family-centered care for hospitalized individuals: Best practices for hospitalist care teams.

Traditionally, hospital medicine services have been dominated by the physician and hospital team, with significant barriers to patient- and family-centered care. This article offers principles and associated strategies to reduce those barriers and guide implementation of systemically informed, collaborative, and culturally responsive patient- and family-centered care provided by hospitalist care teams, especially regarding collaborative decision-making for treatment and discharge planning. Such an approach is associated with reduced lengths of stay and hospital costs and lowered rates of medical errors and mortality. It also is linked to improved patient and family cooperation and adherence; enhanced quality of care and clinical outcomes; and increased levels of satisfaction among health care professionals, patients, and families. Such care uses resources wisely and is effective and ethical. We hope articulating and illustrating these principles and strategies will facilitate efforts to shift the health care culture from being physician-centered to truly team-, patient-, and family-centered. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Trauma exposure and stress-related disorders in African-American women with diabetes mellitus.

OBJECTIVE: The purpose of the study was to assess demographic features, rates of trauma exposure, prevalence of post-traumatic stress and depressive symptoms in a group of urban, low-income, African-American women with type 1 or type 2 diabetes mellitus. RESEARCH DESIGN AND METHODS: We conducted a survey of (n = 290) low-income, African-American women seeking care in the diabetes clinic of an urban hospital and collected data on the demographic characteristics, childhood and nonchildhood abuse trauma exposure, and the severity of post-traumatic stress and depressive symptoms using the Post-traumatic Stress Disorder (PTSD) Symptom Scale (PSS) and the Beck Depression Inventory (BDI). In a subset of women with type 2 diabetes (n = 96), we assessed haemoglobin A1c to examine the relationship between psychopathology and glycaemic control. RESULTS: Of the overall sample, 61.7% reported exposure to trauma in their lifetime, and 30.4% and 29.3% had current PTSD and MDD, respectively. Exposure to both childhood and nonchildhood abuse trauma was associated with an increased PTSD and depressive symptom severity (P's < .05). PTSD diagnosis, but not depression, was associated with increased haemoglobin A1c (P = .002). CONCLUSIONS: These data document high levels of trauma exposure, PTSD and depressive symptoms in diabetic African-American women treated in a specialty clinic of an urban hospital setting. Furthermore, these data indicate that the presence of PTSD is negatively associated with glycaemic control.