International Medical Graduates in Psychiatry: Cultural Issues in Training and Continuing Professional Development.

A position paper developed by the Canadian Psychiatric Association's Education Committee and approved by the CPA's Board of Directors on August 15, 2016.

I think I'm Going to be Sick: An Eight-Year-Old Boy with Emetophobia and Secondary Food Restriction.

We present a case of an eight-year-old boy with a specific phobia of vomiting who developed subsequent food restriction and weight loss. Our case report includes a review of treatment modalities for specific phobias including cognitive behavioural and exposure therapy in young children and the importance of parental involvement in the treatment process. After an initial assessment and diagnosis of this boy with emetophobia, treatment took place over ten subsequent visits, one hour each in duration. His treatment included a cognitive approach utilizing exposure therapy to re-introduce foods to his diet, working through a fear hierarchy, addressing cognitive distortions/misconceptions and psychoeducational supports. Intermittent reinforcement was applied to help extinguish what we believe was an associatively learned fear of vomiting. Outcomes of the treatment were measured by changes in behaviour and overall increase in food intake reported by the patient's parents. On completion of treatment, the family was no longer concerned with the amount and variety of food he was eating, the patient reported less nausea, and he was more likely to eat in public. A post-treatment three-week telephone follow-up showed continued gains. Congruent with reported literature , this case confirms and highlights the efficacy of exposure therapy and age-appropriate cognitive treatment adaptations in treatment of emetophobia. In addition, parental education and participation is recommended in treatment of child cases.

Nous présentons un cas d'un garçon de 8 ans ayant une phobie de vomir spécifique et qui a développé subséquemment une restriction alimentaire et une perte de poids. Notre étude de cas comprend une revue des modalités de traitement pour les phobies spécifiques, dont la thérapie cognitivo-comportementale et la thérapie d'exposition chez les jeunes enfants, et l'importance de la participation parentale au processus du traitement. Après une évaluation initiale et un diagnostic de ce garçon souffrant d'émétophobie, le traitement a eu lieu en 10 visites subséquentes, d'une heure chacune. Son traitement comprenait une approche cognitive qui utilisait une thérapie d'exposition afin de réintroduire la nourriture dans son alimentation, de travailler à la hiérarchie des peurs, d'aborder les distorsions/méconnaissances cognitives et les soutiens psycho-éducatifs. Le renforcement intermittent a été utilisé pour aider à éteindre ce que nous croyions être une peur de vomir apprise par association. Les résultats du traitement ont été mesurés par les changements de comportement et par l'augmentation globale de l'apport alimentaire rapportée par les parents du patient. Au terme du traitement, la famille n'était plus inquiète de la quantité et de la variété des aliments qu'il mangeait. Le patient déclarait moins de nausées, et il était plus susceptible de manger en public. Un suivi téléphonique à 3 semaines après le traitement confirmait des gains continus. Conformément à ce que rapporte la littérature, ce cas confirme et souligne l'efficacité de la thérapie d'exposition et les adaptations appropriées à l'âge du traitement cognitif pour le traitement de l'émétophobie. En outre, l'éducation et la participation des parents sont recommandées dans le traitement des cas d'enfants.

Canadian Rural/Remote Primary Care Physicians Perspectives on Child/Adolescent Mental Health Care Service Delivery.

INTRODUCTION: Primary Care Physicians (PCP) play a key role in the recognition and management of child/adolescent mental health struggles. In rural and under-serviced areas of Canada, there is a gap between child/adolescent mental health needs and service provision. METHODS: From a Canadian national needs assessment survey, PCPs' narrative comments were examined using quantitative and qualitative approaches. Using the phenomenological method, individual comments were drawn upon to illustrate the themes that emerged. These themes were further analyzed using chi-square to identify significant differences in the frequency in which they were reported. RESULTS: Out of 909 PCPs completing the survey, 39.38% (n = 358) wrote comments. Major themes that emerged were: 1) psychiatrist access, including issues such as long waiting lists, no child/adolescent psychiatrists available, no direct access to child/adolescent psychiatrists; 2) poor communication/continuity, need for more systemized/transparent referral processes, and need to rely on adult psychiatrists; and, 3) referral of patients to other mental health professionals such as paediatricians, psychologists, and social workers. CONCLUSIONS: Concerns that emerged across sites primarily revolved around lack of access to care and systems issues that interfere with effective service delivery. These concerns suggest potential opportunities for future improvement of service delivery. IMPLICATIONS: Although the survey only had one comment box located at the end, PCPs wrote their comments throughout the survey. Further research focusing on PCPs' expressed written concerns may give further insight into child/adolescent mental health care service delivery systems. A comparative study targeting urban versus rural regions in Canada may provide further valuable insights.

INTRODUCTION: Les médecins de soins de première ligne (MSPL) jouent un rôle essentiel dans la reconnaissance et la prise en charge des problèmes de santé mentale des enfants/adolescents. Dans les régions rurales et sous-desservies du Canada, il y a un écart entre les besoins de santé mentale des enfants/adolescents et la prestation de services. MÉTHODES: Tirés d'un sondage canadien national évaluant les besoins, les commentaires narratifs des MSPL ont été examinés à l'aide d'approches quantitatives et qualitatives. Au moyen de la méthode phénoménologique, les commentaires individuels ont servi à illustrer les thèmes dégagés. Ces thèmes ont ensuite été analysés avec le chi-carré afin d'identifier les différences significatives de la fréquence à laquelle ils étaient mentionnés. RÉSULTATS: Sur les 909 MSPL qui ont répondu au sondage, 39,38% (n = 358) ont écrit des commentaires. Les thèmes majeurs qui se sont dégagés étaient: 1) l'accès aux psychiatres, notamment des questions comme les longues listes d'attente, pas de pédopsychiatres disponibles, pas d'accès direct aux pédopsychiatres; 2) mauvaise communication/continuité, besoin de processus plus nombreux d'aiguillage systémique/transparent, et besoin de consulter des psychiatres pour adultes; 3) adresser les patients à d'autres professionnels de la santé comme les pédiatres, les psychologues et les travailleurs sociaux. CONCLUSIONS: Les préoccupations soulevées dans les divers centres s'articulaient autour de l'accès aux soins et des problèmes des systèmes qui empiètent sur la prestation efficace de services. Ces préoccupations suggèrent des possibilités pour l'amélioration future de la prestation de services. Implications: Bien que le sondage n'ait offert qu'un espace pour les commentaires à la fin, les MSPL ont écrit leurs commentaires sur tout le sondage. D'autres recherches portant sur les commentaires écrits des MSPL peuvent offrir d'autres idées sur les systèmes de prestation de services de santé mentale aux enfants/adolescents Une étude comparative ciblant les régions urbaines par rapport aux régions rurales du Canada peut fournir un apport valable.

Psychiatrists' and Psychiatry Residents' Attitudes Toward Transgender People.

OBJECTIVE: Gender minority groups, such as transgender individuals, frequently encounter stigma, discrimination, and negative mental health outcomes, which can result in contact with mental health professionals. Recent studies suggest that negative attitudes toward transgender individuals are prevalent and measurable within the general population. The Genderism and Transphobia scale (GTS) measures anti-transgender feelings, thoughts, and behaviors. The purpose of this study was to use the GTS to conduct an investigation of psychiatrists' attitudes toward transgender individuals. METHODS: A cross-sectional survey of n = 142 faculty members and residents from the Department of Psychiatry at the University of Manitoba was conducted. Respondents completed an online survey consisting of demographic questions and the GTS. Responses were analyzed descriptively and compared to previously published data on the GTS. RESULTS: There was a trend for psychiatrists and psychiatry residents within this sample to endorse less negative attitudes toward transgender people compared to other published data using a sample of undergraduate students. Descriptive analyses suggest that psychiatrists' and psychiatry residents' GTS scores may be related to gender identity, political ideology, religiosity, and levels of both professional and personal contact. CONCLUSIONS: These data evoke optimism regarding psychiatrists' and psychiatry residents' attitudes toward transgender individuals. Additional larger-scale studies comparing this medical specialty group with other specialty groups will further elucidate factors that modify physician attitudes toward this patient population. These findings may contribute to the development of educational strategies to ensure that the transgender population receives medical treatment without stigma or attitudinal compromise.

The University of Manitoba Psychiatry Toolkit: Development and Evaluation.

OBJECTIVE: The authors developed and measured the subsequent utilization of a web-based point-of-care information tool and meta-search filter, the University of Manitoba Psychiatry Toolkit, as well as conduct an evaluation of its impact on physicians' information seeking. METHODS: Evaluation entailed analysis of toolkit web page utilization data from user visits to the web-based toolkit, as well as an online survey distributed to psychiatrists and resident trainees to assess information gathering behaviors and attitudes regarding various sources of medical information. RESULTS: Electronic resources and colleagues were the preferred sources for gathering health information, while inadequate time and search skills were ranked as important barriers. Age and physician cadre influenced toolkit use. Majority of respondents used the Psychiatry Toolkit to answer a clinical question, and urgency of the clinical problem influenced their decision to use it. CONCLUSIONS: The Psychiatry Toolkit assists psychiatrists and residents in finding answers to clinical questions arising at point-of-care, helping enhance the ongoing educational needs of physicians.

Determinants of first practice location: among Manitoba medical graduates.

OBJECTIVE: To help understand physician movement out of Manitoba by determining the factors that influence Manitoba medical graduates' choices about practice locations. DESIGN: Cross-sectional, within-stage, mixed-model survey. SETTING: Manitoba. PARTICIPANTS: All University of Manitoba medical graduates from classes 1998 to 2009 for whom we had valid contact information (N = 912 of 943 graduates) were invited in August 2009 to participate in a survey. MAIN OUTCOME MEASURES: Demographic information; ratings, on a 5-point scale, of the importance when choosing first practice locations of 12 practice characteristics, 3 recruitment strategies, and 4 location characteristics listed in the survey; free-text narratives on unlisted factors; and estimates of likely practice location upon completion of training for recent graduates still in residency training. RESULTS: Completed surveys were received from 331 (35.1%) graduates of the surveyed classes, 162 (53.3%) of whom chose Manitoba for their first practice location. Multiple regression analyses indicated that graduates choosing Manitoba for their first practice location were significantly more likely to have done their residency training in Manitoba (P < .05), whether or not they gave a high rating to the importance of being near family and friends. Also, graduates choosing Manitoba were significantly more likely to be recent graduates (P = .007) and less likely to be members of a visible minority (P = .018). These associations were robust even when analyses were restricted to responses from practitioners without cause to estimate practice locations. Early self-selection of graduates during entry into specific residency programs, results of the residency match process, and "putting down roots" during residency years were 3 important interrelated themes identified through qualitative analyses. CONCLUSION: Residency education in Manitoba is the overwhelming factor influencing graduates' choice of Manitoba as their first practice location, regardless of graduates' rating of the importance of being near family or friends. Graduates' narratives provided insights into the complexities of choosing practice locations and enhanced the interpretive and theoretical validity of the study findings. More extensive studies involving all Canadian residents could further define the role residency location plays in physician practice location.

Referral Patterns and Training Needs in Psychiatry among Primary Care Physicians in Canadian Rural/Remote Areas.

OBJECTIVES: This study examined the referral patterns of rural/remote primary care physicians (PCPs) as well as their needs and interests for further training in child/adolescent mental health. METHODS: Surveys were mailed to Canadian rural/remote PCPs requesting participants' demographic information, training and qualifications, referral patterns, and identification of needs and interests for continuing medical education (CME). RESULTS: PCPs were most likely to refer to mental health programs, and excessive wait times are the most common deterrent. Major reasons for referral were to obtain recommendations regarding medications and assessing non-responsive patients. While PCPs expressed higher levels of confidence in making appropriate referrals, they were much less confident in their knowledge and skills in managing mental health problems. Professional development in child/adolescent psychiatry is a moderate or highly perceived CME need. Overall, attention deficit/hyperactivity disorder (ADHD) was the most commonly chosen topic of interest and CME in the community was preferred, but some regional differences emerged. CONCLUSIONS: PCPs viewed limited community resources and self-identified gaps in skills as barriers to service provision. Professional development in child and adolescent mental health for PCPs by preferred modes appears desired.

Childhood adversity and personality disorders: results from a nationally representative population-based study.

BACKGROUND: Although, a large population-based literature exists on the relationship between childhood adversity and Axis I mental disorders, research on the link between childhood adversity and Axis II personality disorders (PDs) relies mainly on clinical samples. The purpose of the current study was to examine the relationship between a range of childhood adversities and PDs in a nationally representative sample while adjusting for Axis I mental disorders. METHODS: Data were from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; n=34,653; data collection 2004-2005); a nationally representative sample of the United States population aged 20 years and older. RESULTS: The results indicated that many types of childhood adversity were highly prevalent among individuals with PDs in the general population and childhood adversity was most consistently associated with schizotypal, antisocial, borderline, and narcissistic PDs. The most robust childhood adversity findings were for child abuse and neglect with cluster A and cluster B PDs after adjusting for all other types of childhood adversity, mood disorders, anxiety disorders, substance use disorders, other PD clusters, and sociodemographic variables (Odd Ratios ranging from 1.22 to 1.63). In these models, mood disorders, anxiety disorders, and substance use disorders also remained significantly associated with PD clusters (Odds Ratios ranging from 1.26 to 2.38). CONCLUSIONS: Further research is necessary to understand whether such exposure has a causal role in the association with PDs. In addition to preventing child maltreatment, it is important to determine ways to prevent impairment among those exposed to adversity, as this may reduce the development of PDs.

The relationship between child abuse, parental divorce, and lifetime mental disorders and suicidality in a nationally representative adult sample.

OBJECTIVES: To determine how the experiences of child abuse and parental divorce are related to long-term mental health outcomes using a nationally representative adult sample after adjusting for sociodemographic variables and parental psychopathology. METHODS: Data were drawn from the National Comorbidity Survey (NCS, n=5,877; age 15-54 years; response rate 82.4%). Logistic regression models were used to determine the odds of experiencing lifetime psychiatric disorders and suicidal ideation and attempts. RESULTS: Parental divorce alone was associated with some psychiatric disorders after adjusting for sociodemographic variables (AOR ranging from 1.30 to 2.37), while child abuse alone was associated with psychiatric disorders (AOR ranging from 1.39 to 6.07) and suicidal ideation (AOR=2.08; 95% CI=1.57-2.77) and attempts (AOR=1.54; 95% CI=1.02-2.31) after adjusting for sociodemographic variables. However, having experienced both parental divorce and child abuse together resulted in significantly increased odds for lifetime PTSD (AOR=9.87; 95% CI=6.69-14.55), conduct disorder (AOR=4.01; 95% CI=2.92-5.51) and suicide attempts (AOR=2.74; 95% CI=1.84-4.08) compared to having experienced either parental divorce or child abuse alone. These results were attenuated when further adjusting for parental psychopathology. CONCLUSIONS: When the experience of parental divorce is accompanied with child abuse, the associations with some poor mental health outcomes are significantly greater compared to the impact of either parental divorce or child abuse on its own. Therefore, parental divorce is an additional childhood adversity that significantly contributes to poor mental health outcomes especially when in combination with child abuse. Parental psychopathology attenuated these relationships suggesting that it may be one possible mechanism to explain the relationships between child abuse, parental divorce, and psychiatric disorders and suicide attempts.

Childhood adversity and perceived need for mental health care: findings from a Canadian community sample.

Previous community surveys have demonstrated that individuals with self-perceived need for mental health treatment in combination with meeting DSM-III-R criteria display the greatest levels of impairment in the community and have a higher likelihood of reporting parental psychopathology. The current investigation aims to replicate and extend these findings by examining the association between a wide range of childhood adversities with self-perceived need for mental health treatment and DSM-III-R diagnosis in a Canadian community sample (N = 8116). All respondents were questioned about their childhood experiences (physical and sexual abuse, emotional neglect, parental discord/separation, parental death, and parental psychopathology). After controlling for covariates in a multiple logistic regression, we found that emotional neglect (OR = 2.07), physical abuse (OR = 2.16), sexual abuse (OR = 2.39), paternal psychopathology (OR = 2.41), and maternal psychopathology (OR = 2.70) were independently and significantly associated with respondents meeting DSM criteria for a mental disorder and perceiving a need for treatment. These findings underscore the importance of future longitudinal studies considering the influence of a wide range of early childhood adversities on adult psychopathology and perceived need for treatment.

Mental health sequelae of bullying: a review and case report.

This paper is a review of the effects of bullying on children and adolescents. We begin with a case report of a young male who presented at a children's hospital emergency room after being subjected to months of bullying. We then proceed to a review of relevant literature, and focus on a definition of bullying, the incidence of this problem, and the characteristics of bullies, victims and those who both bully and are bullied. The consequences of this behaviour, both for the perpetrator and victim, are also examined. We note that all individuals who participate in bullying, whether as perpetrators, victims, or those who have been both the perpetrators and the targets of this particular form of aggression, have in some way been psychologically affected by such experiences. It is hoped that the significance of bullying behaviour, and its psychological cost on the psychological well-being of the children and adolescents involved with bullying, will be a central theme of this review.

Comparative study of trauma-related phenomena in subjects with pseudoseizures and subjects with epilepsy.

OBJECTIVE: The purpose of this study was to examine potential differences in measures of trauma-related phenomena between subjects with pseudoseizures and subjects with intractable epilepsy. METHOD: Thirty-one adult subjects with pseudoseizures and 32 subjects with intractable epilepsy (confirmed by video-EEG) were recruited from the epilepsy unit of a tertiary care hospital. Each participant completed the Impact of Event Scale, the Davidson Trauma Scale, the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder (PTSD), the Dissociative Experience Scale, and the Pittsburgh Sleep Quality Index, as well as demographic, seizure history, and family functioning measures. RESULTS: Subjects with pseudoseizures had significantly higher mean scores on the Davidson Trauma Scale, Mississippi Scale for Combat-Related PTSD, Impact of Event Scale, and Pittsburgh Sleep Quality Index than subjects with epilepsy. In addition, a significantly higher percentage of subjects with pseudoseizures had scores above the clinical cutoff level of 30 on the Dissociative Experience Scale. CONCLUSIONS: Subjects with pseudoseizures exhibited trauma-related profiles that differed significantly from those of epileptic comparison subjects and closely resembled those of individuals with a history of traumatic experiences. Interventions aimed at trauma-related issues may be beneficial for patients with pseudoseizures.