Language is brain: Improving neurologic health equity for linguistically diverse populations.

Neurologic clinical care requires that clinicians gather and synthesize complex information, including a thorough, precise history and a detailed physical examination that maximizes the patient's cooperation. Yet, for patients who do not speak the dominant language in the country or region where they live, effective communication with their clinician may not always occur. In this article, we discuss the impact of language on neurologic care, focusing on access to care and on the diagnosis and treatment of two common and potentially life-threatening conditions: stroke and epilepsy. We then review implications for clinical neurologic care as well as medical education and present evidence-based recommendations for improving neurologic health equity for linguistically diverse populations. Strategies should integrate professional medical interpreters (for oral communication) and translators (for written materials) into the neurologic team, account for families and caregivers in a culturally humble manner, and teach learners to apply clinical neurologic skills in both language-concordant and discordant situations.

Amyloid and Tau in Alzheimer's Disease: Biomarkers or Molecular Targets for Therapy? Are We Shooting the Messenger?

Alzheimer's disease is a neuropsychiatric disorder with devastating clinical and socioeconomic consequences. Since the original description of the neuropathological correlates of the disorder, neuritic plaques and neurofibrillary tangles have been presumed to be critical to the underlying pathophysiology of the illness. The authors review the clinical and neuropathological origins of Alzheimer's disease and trace the evolution of modern biomarkers from their historical roots. They describe how technological innovations such as neuroimaging and biochemical assays have been used to measure and quantify key proteins and lipids in the brain, cerebrospinal fluid, and blood and advance their role as biomarkers of Alzheimer's disease. Together with genomics, these approaches have led to the development of a thematic and focused science in the area of degenerative disorders. The authors conclude by drawing distinctions between legitimate biomarkers of disease and molecular targets for therapeutic intervention and discuss future approaches to this complex neurobehavioral illness.

Neuroscience Education: Making It Relevant to Psychiatric Training.

Psychiatric education has struggled to move past dualistic notions separating mind from brain, and embrace the field's identity as a clinical neuroscience discipline. To modernize our educational systems, we must integrate neuroscience perspectives into every facet of our clinical work. To do this effectively, neuroscience education should be clinically relevant, informed by adult learning theory, and tailored to the individualized needs of learners. Classic neuropsychiatry skills can help us better understand our patients' brain function at the bedside. Integrating neuroscience perspectives alongside the other rich perspectives in psychiatry will help trainees appreciate the relevance of neuroscience to modern medical practice.

Electroconvulsive Therapy for Patients with Catatonia: Current Perspectives.

Catatonia is a serious, common syndrome of motoric and behavioral dysfunction, which carries high morbidity and mortality. Electroconvulsive therapy (ECT) is the definitive treatment for catatonia, but access to ECT for the treatment of catatonia remains inappropriately limited. Catatonia is observable, detectable, and relevant to various medical specialties, but underdiagnosis impedes the delivery of appropriate treatment and heightens risk of serious complications including iatrogenesis. Current understanding of catatonia's pathophysiology links it to the current understanding of ECT's mechanism of action. Definitive catatonia care requires recognition of the syndrome, workup to identify and treat the underlying cause, and effective management including appropriate referral for ECT. Even when all of these conditions are met, and despite well-established data on the safety and efficacy of ECT, stigma surrounding ECT and legal restrictions for its use in catatonia are additional critical barriers. Addressing the underdiagnosis of catatonia and barriers to its treatment with ECT is vital to improving outcomes for patients. While no standardized protocols for treatment of catatonia with ECT exist, a large body of research guides evidence-based care and reveals where additional research is warranted. The authors conducted a review of the literature on ECT as a treatment for catatonia. Based on the review, the authors offer strategies and future directions for improving access to ECT for patients with catatonia, and propose an algorithm for the treatment of catatonia with ECT.

Physical Examination Skills Among Chief Residents in Psychiatry: Practices, Attitudes, and Self-Perceived Knowledge.

OBJECTIVES: The authors investigated the attitudes, self-perceived competence, and the need for a dedicated curriculum on physical examination skills among chief residents in psychiatry. METHODS: A voluntary 28-item web-based questionnaire was distributed to psychiatry chief residents in the USA between January 2019 and February 2019. RESULTS: Of 181 chief residents, 79 (response rate, 44%) completed the online survey. The majority of chief residents want to improve their physical exam skills (64%) and believe that there should be a targeted curriculum aimed at incorporating these skills into everyday psychiatric practice (63%). However, most (57%) chief residents reported that they only conduct physical exams on a few selected patients (< 25% of the time) and almost half (48%) last used a stethoscope a year ago, if not longer. Self-perceived competence and comfort level with neurology-related exam findings was especially low: only 35% could identify discrepant neurological findings and 33% elicit Hoover's sign of leg paresis. A significant majority (86%) believed that performing a physical exam would not interfere with the therapeutic relationship. CONCLUSIONS: Although chief residents in psychiatry believe that developing competence in physical examinations is important to their education, the current educational landscape does not support the development of these skills. Future educational strategies should focus on addressing this need.

Transforming Psychiatry from the Classroom to the Clinic: Lessons from the National Neuroscience Curriculum Initiative.

OBJECTIVE: Individual residency programs often struggle to keep pace with scientific advances and new training requirements. Integrating a modern neuroscience perspective into the clinical practice of psychiatry is particularly emblematic of these challenges. The National Neuroscience Curriculum Initiative (NNCI) was established in 2013 to develop a comprehensive set of shared, open-access resources for teaching neuroscience in psychiatry. METHODS: The NNCI developed a collaborative, team-based approach with a peer-review process for generating and reviewing content. Teaching resources have included interactive sessions for the classroom paired with a comprehensive facilitator's guide. Brief accessible reviews and short videos have been developed for self-study and teaching in clinical settings. Dissemination efforts have included hands-on training for educators through national workshops. All resources are freely available on the NNCI website. Outcome measures have included the number of educational resources developed, feedback from workshop attendees, the number of US psychiatry residency programs who have adopted NNCI resources, as well as analytics from the NNCI website. RESULTS: To date, the NNCI has developed over 150 teaching sessions, reflecting the work of 129 authors from 49 institutions. The NNCI has run over 50 faculty development workshops in collaboration with numerous national and international organizations. Between March 2015 and June 2019, the website (www.NNCIonline.org) has hosted 48,640 unique users from 161 countries with 500,953 page views. More than 200 psychiatry training programs have reported implementing NNCI teaching materials. CONCLUSIONS: This multisite collaborative provides a model for integrating cutting-edge science into medical education and the practice of medicine more broadly.

Neuroimaging Education in Psychiatry Residency Training: Needs Assessment.

OBJECTIVE: The authors investigated the attitudes, self-perceived knowledge, and the need for a dedicated neuroimaging curriculum among psychiatrists-in-training. METHODS: An anonymous voluntary 20-item Web-based survey was distributed to psychiatry residents at seven university-based USA programs between December 2017 and February 2019. RESULTS: Of 302 psychiatry residents, 183 (response rate, 60.5%) completed the survey. Although a large majority of residents (83%) believed that neuroradiology education is important to psychiatric training, only 7% reported that they are receiving adequate training in this discipline. The majority (80%) believed that there should be a formal neuroimaging curriculum during their training. Self-perceived competence and comfort level was found to be low with several psychiatrically relevant neuroimaging modalities. In particular, regarding CT head/brain MRI, there was a marked difference in self-perceived competence at interpreting the actual brain images (8%) versus the radiological reports/impression summaries (48%). Comfort level with functional neuroimaging was especially low (7%). Clinically, only 26% reported confidence at being able to explain neuroimaging topics to patients. Compared to junior residents, senior residents rated higher confidence at interpreting the radiological reports/impression summaries of CT head/brain MRI (p = 0.008) and PET/SPECT (p = 0.014), but no difference was found with the actual brain images. Further, senior residents were less likely to identify with "neurophobia" (p = 0.028) and more likely to believe that a neuroimaging curriculum should be included in psychiatric residency training (p = 0.027) when compared to junior residents. CONCLUSIONS: Psychiatrists-in-training have a very strong interest in neuroimaging education. Future educational interventions should address this need.

Anti-N-Methyl-D-Aspartate Receptor Encephalitis: A Review of Psychiatric Phenotypes and Management Considerations: A Report of the American Neuropsychiatric Association Committee on Research.

OBJECTIVE: Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune disorder characterized by prominent neuropsychiatric symptoms. Given the nature of its pathophysiology, psychiatrists tend to be one of the first clinicians encountering patients with the disease. METHODS: In the present review of patients described in the literature with psychiatric symptoms, the authors aimed to characterize the psychiatric symptoms of the disease and its management in adults and adolescents as well as children (≤12 years old). A total of 544 patients fulfilled the inclusion criteria. RESULTS: The authors found that 77% of patients with NMDAR encephalitis presented initially with psychiatric symptoms. These were mostly agitation (59%) and psychotic symptoms (in 54%, especially disorganized behavior and visual-auditory hallucinations), with agitation even more commonly being the presenting symptom in children (66%). Where psychotic symptoms were detailed, visual (64%) and auditory (59%) hallucinations were the most common, as well as persecutory delusions (73%). However, delusions were not clearly characterized in most cases. Catatonia was described in 42% of adult patients and 35% of children. Of the patients with documented exposure to antipsychotics, 33% were suspected to have an adverse drug reaction (notably, neuroleptic malignant syndrome in 22% of the cases). CONCLUSIONS: On the basis of these findings, it is important to consider anti-NMDAR encephalitis in the differential diagnosis of patients with an acute onset psychosis, especially in association with agitation, catatonia, or adverse response to antipsychotics. Furthermore, it is important to use antipsychotics with caution in patients with suspected or confirmed anti-NMDAR encephalitis.