Longitudinal Outcomes of a Resident Academic Administrator, Clinician Educator Track.

OBJECTIVE: As clinician educator tracks continue to gain popularity in graduate medical education, this report aims to fill a gap in the literature by providing a 14-year update on professional outcomes of participants in a psychiatry residency academic administrator, clinician educator (AACE) track and to compare these outcomes to non-track participants. METHODS: An anonymous web-based survey querying professional achievements was distributed to all graduates of a psychiatry residency training program from 2009 to 2022. Outcomes of AACE track participants and non-track participants were compared. RESULTS: Of 228 alumni contacted, 61% responded (n = 140). Eighty-seven percent of track participants responded (n = 74) while 41% of non-track participants responded (n = 45). Of track participants, 63% practice in academic settings with 57% having held administrative leadership roles, 49% educational leadership roles, and 39% national or regional leadership roles. Track graduates were academically engaged with 70% reporting at least one publication, 89% at least one presentation, and 93% attending at least one national meeting. In comparison, 31% of non-track participants practice in academic settings with 44% having held administrative, 29% educational, and 20% national or regional leadership roles. Thirty-nine percent have at least one publication, 75% at least one presentation, and 90% attended at least one national meeting. When compared to non-track participants, track participants were significantly more likely to have an academic affiliation and a higher number of publications and were more likely to hold national or regional leadership roles. CONCLUSIONS: Track participants demonstrate longitudinal career success as clinician educators and academic administrators more so than non-track participants.

An Overview for the General Psychiatrist Evaluating Patients With Obstetric and Neonatal Complications and Perinatal Loss.

When neonatal and obstetrical complications occur, the identification and management of mood and anxiety disorders become complex with an ever-expanding array of psychiatric needs that include the management of grief- and trauma-related disorders. With high rates of maternal morbidity and mortality in the United States and laws in many states restricting reproductive health access, psychiatrists must be proficient in managing psychiatric sequelae in this context. High-risk groups for peripartum mood and anxiety disorders, posttraumatic stress disorder, and complicated grief include those with neonatal intensive care unit (NICU) stays and those who have experienced infertility and recurrent pregnancy loss. Groups who have been historically marginalized by the medical system (e.g., Black, Indigenous, people of color) and those from LGBTQ+ communities are at similarly high risk, and more interventions are needed to support these groups. Strategies emphasizing trauma-informed care, psychotherapeutic approaches, and using patient-centered language are recommended.

Predicting first time depression onset in pregnancy: applying machine learning methods to patient-reported data.

PURPOSE: To develop a machine learning algorithm, using patient-reported data from early pregnancy, to predict later onset of first time moderate-to-severe depression. METHODS: A sample of 944 U.S. patient participants from a larger longitudinal observational cohortused a prenatal support mobile app from September 2019 to April 2022. Participants self-reported clinical and social risk factors during first trimester initiation of app use and completed voluntary depression screenings in each trimester. Several machine learning algorithms were applied to self-reported data, including a novel algorithm for causal discovery. Training and test datasets were built from a randomized 80/20 data split. Models were evaluated on their predictive accuracy and their simplicity (i.e., fewest variables required for prediction). RESULTS: Among participants, 78% identified as white with an average age of 30 [IQR 26-34]; 61% had income ≥ $50,000; 70% had a college degree or higher; and 49% were nulliparous. All models accurately predicted first time moderate-severe depression using first trimester baseline data (AUC 0.74-0.89, sensitivity 0.35-0.81, specificity 0.78-0.95). Several predictors were common across models, including anxiety history, partnered status, psychosocial factors, and pregnancy-specific stressors. The optimal model used only 14 (26%) of the possible variables and had excellent accuracy (AUC = 0.89, sensitivity = 0.81, specificity = 0.83). When food insecurity reports were included among a subset of participants, demographics, including race and income, dropped out and the model became more accurate (AUC = 0.93) and simpler (9 variables). CONCLUSION: A relatively small amount of self-report data produced a highly predictive model of first time depression among pregnant individuals.

Lung Cancer Clinical Trials in Latin America in the Era of Cooperative Groups: A 20-Year Analysis.

PURPOSE: The aim of this study is to characterize lung cancer treatment clinical trials in Latin America before (January 2001-December 2011) and after (January 2012-December 2021) the organization of major Latin American oncology cooperative groups. MATERIALS AND METHODS: Interventional clinical trials were identified in ClinicalTrials.gov using the search terms "lung cancer," country filters for 20 Latin American countries, and study start dates January 1, 2001-December 31, 2011, and January 1, 2012-December 31, 2021. Clinical trials were categorized as either originating in Latin America (LA) or outside Latin America (non-LA) with participation of Latin American countries. Descriptive statistics, two-sided Z-scores, and chi-square analyses with 95% CIs were calculated. RESULTS: Overall, 273 clinical trials involving Latin American countries between 2001 and 2021 were identified. Comparing 2001-2011 with 2012-2021, there was an increase in total clinical trials (100 v 173; P < .001). Only 9% (26 of 273) of all trials were LA trials. There was a marked decrease in the proportion of LA trials (14% v 7%, P = .058) and estimated enrollment to LA trials (3,245 v 1,190 patients; P < .001). Recruiting of patients with EGFR (29% v 7%; P < .01) and KRAS (18% v 2%; P < .01) driver mutations also decreased. Trial participation was highest in Brazil, Mexico, Argentina, Chile, and Peru and increased over time: Brazil (61 v 108; 77% increase), Mexico (40 v 88; 120% increase), Argentina (50 v 78; 56% increase), Chile (25 v 57; 128% increase), and Peru (14 v 37; 164% increase). CONCLUSION: There was a significant increase in clinical trial participation by Latin American countries, from 2001-2011 to 2012-2021. However, there were few clinical trials which originated in Latin America or focused on patients with driver mutations.

Impact of Preexisting Depression and Anxiety on Hospital Readmission and Long-Term Survival After Cardiac Arrest.

BACKGROUND: While sudden cardiac arrest (CA) survivors are at risk for developing psychiatric disorders, little is known about the impact of preexisting mental health conditions on long-term survival or postacute healthcare utilization. We examined the prevalence of preexisting psychiatric conditions in CA patients who survived hospital discharge, characterized incidence and reason for inpatient psychiatry consultation during these patients' acute hospitalizations, and determined the association of pre-CA depression and anxiety with hospital readmission rates and long-term survival. We hypothesized that prior depression or anxiety would be associated with higher hospital readmission rates and lower long-term survival. METHODS: We conducted a retrospective cohort study including patients resuscitated from in- and out-of-hospital CA who survived both admission and discharge from a single hospital between January 1, 2010, and December 31, 2017. We identified patients from our prospective registry, then performed a structured chart review to abstract past psychiatric history, prescription medications for psychiatric conditions, and identify inpatient psychiatric consultations. We used administrative data to identify readmissions within 1 year and vital status through December 31, 2020. We used multivariable Cox regressions controlling for patient demographics, medical comorbidities, discharge Cerebral Performance Category and disposition, depression, and anxiety history to predict long-term survival and hospital readmission. RESULTS: We included 684 subjects. Past depression or anxiety was noted in 24% (n = 162) and 19% (n = 129) of subjects. A minority of subjects (n = 139, 20%) received a psychiatry consultation during the index hospitalization. Overall, 262 (39%) subjects had at least 1 readmission within 1 year. Past depression was associated with an increased hazard of hospital readmission (hazard ratio 1.50, 95% CI 1.11-2.04), while past anxiety was not associated with readmission. Neither depression nor anxiety were independently associated with long-term survival. CONCLUSIONS: Depression is an independent risk factor for hospital readmission in CA survivors.

CYP2D6-guided opioid therapy for adults with cancer pain: A randomized implementation clinical trial.

INTRODUCTION: The CYP2D6 enzyme metabolizes opioids commonly prescribed for cancer-related pain, and CYP2D6 polymorphisms may contribute to variability in opioid response. We evaluated the feasibility of implementing CYP2D6-guided opioid prescribing for patients with cancer and reported pilot outcome data. METHODS: Adult patients from two cancer centers were prospectively enrolled into a hybrid implementation-effectiveness clinical trial and randomized to CYP2D6-genotype-guided opioid selection, with clinical recommendations, or usual care. Implementation metrics, including provider response, medication changes consistent with recommendations, and patient-reported pain and symptom scores at baseline and up to 8 weeks, were assessed. RESULTS: Most (87/114, 76%) patients approached for the study agreed to participate. Of 85 patients randomized, 71% were prescribed oxycodone at baseline. The median (range) time to receive CYP2D6 test results was 10 (3-37) days; 24% of patients had physicians acknowledge genotype results in a clinic note. Among patients with CYP2D6-genotype-guided recommendations to change therapy (n = 11), 18% had a change congruent with recommendations. Among patients who completed baseline and follow-up questionnaires (n = 48), there was no difference in change in mean composite pain score (-1.01 ± 2.1 vs. -0.41 ± 2.5; p = 0.19) or symptom severity at last follow-up (3.96 ± 2.18 vs. 3.47 ± 1.78; p = 0.63) between the usual care arm (n = 26) and genotype-guided arm (n = 22), respectively. CONCLUSION: Our study revealed high acceptance of pharmacogenetic testing as part of a clinical trial among patients with cancer pain. However, provider response to genotype-guided recommendations was low, impacting assessment of pain-related outcomes. Addressing barriers to utility of pharmacogenetics results and clinical recommendations will be critical for implementation success.

Preventing and treating delirium in clinical settings for older adults.

Delirium is a serious consequence of many acute or worsening chronic medical conditions, a side effect of medications, and a precipitant of worsening functional and cognitive status in older adults. It is a syndrome characterized by fluctuations in cognition and impaired attention that develops over a short period of time in response to an underlying medical condition, a substance (prescribed, over the counter, or recreational), or substance withdrawal and can be multi-factorial. We present a narrative review of the literature on nonpharmacologic and pharmacologic approaches to prevention and treatment of delirium with a focus on older adults as a vulnerable population. Older adult patients are most at risk due to decreasing physiologic reserves, with delirium rates of up to 80% in critical care settings. Presentation of delirium can be hyperactive, hypoactive, or mixed, making identification and study challenging as patients with hypoactive delirium are less likely to come to attention in an inpatient or long-term care setting. Studies of delirium focus on prevention and treatment with nonpharmacological or medication interventions, with the preponderance of evidence favoring multi-component nonpharmacological approaches to prevention as the most effective. Though use of antipsychotic medication in delirium is common, existing evidence does not support routine use, showing no clear benefit in clinically significant outcome measures and with evidence of harm in some studies. We therefore suggest that antipsychotics be used to treat agitation, psychosis, and distress associated with delirium at the lowest effective doses and shortest possible duration and not be considered a treatment of delirium itself. Future studies may clarify the use of other agents, such as melatonin and melatonin receptor agonists, alpha-2 receptor agonists, and anti-epileptics.

Impact of colocated behavioral health on OB-GYN clinicians' rate of perinatal behavioral health diagnosis and psychotropic prescription.

OBJECTIVE: To examine the association of colocated behavioral health(BH) care with rates of OB-GYN clinician coding of BH diagnoses and BH medications. METHOD: Using 2 years of EMR data from perinatal individuals treated across 24 OB-GYN clinics, we tested the hypothesis that colocated BH care would increase rates of OB-GYN BH diagnoses and psychotropic prescription. RESULTS: Psychiatrist integration(0.1 FTE) was associated with 45.7% higher odds of OB-GYN coding for BH diagnoses and BH clinician integration was associated with 25% lower odds of OB-GYN BH diagnosis and 37.7% lower odds of BH medication prescription. Non-white patients had 28-74% and 43-76% lower odds of having a BH diagnosis and a BH medication ordered, respectively. The most common diagnoses were anxiety and depressive disorders(60%) and the most prescribed BH medications were SSRIs(86%). CONCLUSIONS: OB-GYN clinicians made fewer BH diagnoses and prescribed fewer psychotropics after 2.0 FTE BH clinician integration, a possible indication of external referrals for BH treatment. Non-white patients received BH diagnoses and medications less often than white patients. Future research in real world implementation of BH integration in OB-GYN clinics should examine fiscal strategies that support BH care manager-OB-GYN collaboration as well as methods to ensure equitable delivery of BH care.

A Peer-to-Peer, Longitudinal Reproductive Psychiatry Educational Curriculum for Obstetrics/Gynecology Residents.

OBJECTIVE: Pregnant patients with psychiatric diagnoses are commonly advised to stop their psychiatric medications. Few studies assess the knowledge of, attitude toward, or comfort levels of obstetrics and gynecology (OB/GYN) residents in managing psychiatric conditions, which carry adverse and potentially life-threatening risks to mother and fetus. A gap remains between evidence advocating for active psychopharmacological treatment during pregnancy and implementation of curricula targeting OB/GYN physicians in mental health. The authors' goals are to assess the knowledge, attitude, and comfort that OB/GYN residents have toward assessing and managing active psychiatric conditions in pregnant/postpartum women and to develop an educational, case-based intervention targeting these conditions in the perinatal/postpartum period. METHODS: Eight perinatal/postpartum psychiatric topics were developed into interactive cases designed for OB/GYN residents. Two weeks before the curriculum administration, OB/GYN residents were surveyed on prior knowledge in, attitudes toward, and comfort levels in assessing and discussing psychiatric conditions in pregnant patients. The assessment was administered again after the intervention to assess its effectiveness. RESULTS: Pre- (N = 19) and post-intervention (N = 15) surveys of residents were analyzed. Most residents (94%) felt it was both important and their responsibility to discuss mental health conditions with pregnant patients. Comfort levels with counseling psychiatric patients increased for all eight topics after the educational intervention was implemented, with statistically significant increases (p < 0.05) for five of the topics. CONCLUSIONS: OB/GYN residents feel responsible for caring for pregnant patients with psychiatric illness, and case-based interventions offer an interactive, helpful tool for increasing residents' knowledge and comfort level in treating this patient population.

Trauma-Informed Care for Obstetric and Gynecologic Settings.

PURPOSE: Trauma is common among those seeking Ob-Gyn care and may have pervasive impact on obstetrical and gynecological health, social functioning, and healthcare engagement. While guidelines exist on the detection and treatment of perinatal mood and anxiety disorders within Ob-Gyn care, the role of Ob-gyn clinicians in identifying and addressing patients' traumatic experiences and related symptoms is less clearly delineated. This manuscript provides an overview of trauma-related symptoms in the context of Ob-Gyn care and practical guidance of clinicians aiming to improve their detection and response to trauma in their clinical practice. DESCRIPTION: Posttraumatic stress disorder (PTSD) describes a psychiatric illness which develops as a response to a traumatic event. Women who have experienced trauma are also at increased risk for borderline personality disorder and other psychiatric comorbidities. Postpartum PTSD has particular relevance to obstetrical care. ASSESSMENT: Screening for trauma in Ob-Gyn care can provide an opportunity to address risk and offer targeted intervention. Several brief evidence-based screening tools are available. Individuals who screen positive require assessment of immediate safety and targeted referrals. Trauma informed care describes an approach to healthcare aimed to enhance physical and emotional safety for patients and clinicians. CONCLUSION: Given the prevalence and the potentially devastating and enduring impact of trauma and trauma-related symptoms, there is a critical need to address trauma within Ob-Gyn care. By recognizing the signs of trauma and initiating or referring to appropriate treatments, Ob-Gyn clinicians have a unique opportunity to better understand their patients and to improve their care.

A Pilot Study of Ketamine Infusion after Suicide Attempt: New Frontiers in Treating Acute Suicidality in a Real-World Medical Setting.

Ketamine, in research settings, rapidly reduces suicidal thoughts 2-24 h after a single infusion in patients with high suicidal ideation. In this study, the authors investigate ketamine's effects on suicidality in a real-world sample of recent suicide attempters on a tertiary-care Consultation-Liaison (CL) psychiatry service. Using an open-label design, 16 transdiagnostic CL patients were recruited, 18-65 years old, to receive a single dose of intravenous ketamine (0.5 mg/kg) in the acute medical setting. All were psychiatrically hospitalized post-infusion. Baseline suicidality and depression measures were compared to ratings taken at 24 h, 5 days, 12 days, and 1, 3 and 6 months post-infusion using paired t-tests. Across all measures, rapid, statistically significant decreases (p's < 0.001) were observed with large to very large effect sizes (Cohen's d's: 1.7-8.8) at acute timepoints (24 h; 5 days). These gains were uniformly maintained to 6 months post-infusion. Open-label ketamine appeared to rapidly and robustly reduced suicidal symptoms in an ultra-high-risk, heterogeneous, real-world sample. Ketamine infusion may therefore be a safe, feasible, viable method to rapidly reduce suicidality among medically hospitalized patients after a suicide attempt, with potentially enduring benefits. The current pilot findings suggest ketamine could be readily integrated into the settings where high-risk CL patients already receive healthcare, with the potential to become an important and novel tool in the treatment of suicidality.

Pharmacologic Treatment of Sleep Disorders in Pregnancy.

Pregnancy is a unique physiologic state whose characteristics often predispose women to new-onset sleep disturbances or exacerbations of preexisting sleep disorders. Pregnancy-related factors that can disrupt sleep include heartburn, nocturnal oxytocin secretion, nocturia, and fetal movement. Sleep disorders in pregnancy include insomnia (primary and secondary), restless legs syndrome, and narcolepsy.

Trauma Informed Care in the Obstetric Setting and Role of the Perinatal Psychiatrist: A Comprehensive Review of the Literature.

BACKGROUND: Trauma is highly prevalent, and women are twice as likely as men to develop posttraumatic stress disorder following a traumatic exposure. Consequently, many women entering the perinatal period have trauma histories. In the perinatal period, a trauma history can negatively impact treatment engagement and adversely affect the experience of pregnancy, postpartum, and parenting. A trauma-informed care approach can mitigate these effects. OBJECTIVE: This review aims to summarize literature that can aid psychiatrists in (1) identifying signs and symptoms of trauma in perinatal women, (2) integrating elements of trauma-informed care into perinatal mental health care, and (3) offering interventions that can minimize adverse outcomes for perinatal women and their children. METHODS: A PubMed search was conducted with keywords including trauma, pregnancy, perinatal, posttraumatic stress disorder, postpartum posttraumatic stress disorder, and trauma informed care. RESULTS: Perinatal care, given its somewhat invasive nature, has the potential to traumatize or cause retraumatization. Trauma-related disorders are common and can present or worsen in the perinatal period. Trauma can manifest in multiple forms in this population, including exacerbation of preexisting posttraumatic stress disorder, new onset acute stress disorder in the perinatal period, or postpartum posttraumatic stress disorder secondary to traumatic childbirth. Unaddressed trauma can adversely affect the experience of pregnancy, postpartum, and parenting. Psychiatrists caring for women in the perinatal period are in an ideal position to screen for trauma and offer appropriate intervention. A trauma-informed approach to obstetric care can help clinical teams respond to the unique trauma-related challenges that can arise during obstetric care. Trauma-informed care, with its emphasis on establishing a culture of safety, transparency, trustworthiness, collaboration, and mutuality, can empower health care providers and systems with powerful tools to respond to trauma and its myriad effects in a strengths-based manner. By applying a trauma-informed lens, psychiatrists can help their obstetric colleagues provide patient-centered compassionate care and treatment. CONCLUSIONS: Applying a trauma-informed approach to evaluation and treatment of perinatal populations could decrease the toll trauma has on affected women and their children.

Consultation-Liaison Case Conference: Psychiatric Evaluation and Management Following Gunshot Injury.

We present the case of a 23-year-old female presenting to consultation-liaison psychiatry after admission for multiple gunshot wounds. Top experts in the consultation-liaison field provide guidance for this commonly encountered clinical case based on their experience and a review of the available literature. Key teaching topics include risk factors for gun violence victimization, assessment of psychiatric diagnoses associated with gunshot injury, and management challenges including access to psychiatric care. Specifically, we highlight the high prevalence of trauma-related disorders, substance use disorders, and functional impairment after gunshot injury. We also provide practical guidance on issues of lethality assessment, trauma-informed care, psychiatric management, and community resources that support recovery.