Virtual Reality Simulation for Suicide Risk Assessment Training: Prevalence of Adverse Effects.

OBJECTIVE: Virtual reality (VR) simulation is changing the landscape of simulation-based medical education. Immersive VR allows users to interact with a computer-generated environment and digital avatars using a VR headset and controllers. However, current literature regarding the use of immersive VR simulation in psychiatric medical education is sparse. This study describes its use and considerations regarding tolerability. METHODS: At a mental health hospital in Canada, two immersive VR suicide risk assessment (SRA) case simulations were developed. These simulations have participants interview VR patients to characterize their suicide risk, offering a novel and safe way to engage healthcare providers in SRA training. Regarding user tolerability of these VR simulations, the Simulator Sickness Questionnaire (SSQ) was administered to participants after the simulation to characterize any motion sickness symptoms experienced. RESULTS: Of the 22 participants in this study, the overall SSQ scores demonstrated good tolerability of the VR SRA, with the majority of participants reporting no or minimal simulator sickness symptoms. Moreover, the majority of participants reported being satisfied with this training and that the VR SRA simulation enhanced their learning experience. CONCLUSION: These study findings are novel, given the current dearth of data regarding the use of immersive VR in simulation-based psychiatric medical education. Further studies exploring the educational effectiveness of VR SRA in simulation-based psychiatric medical education are indicated.

An Immersive Simulation to Build Empathy for Geriatric Patients with Co-Occurring Physical and Mental Illness.

OBJECTIVE: The objective of the study was to explore the effectiveness of an immersive simulation experience using an aging simulation suit for fostering empathy towards geriatric patients with advanced mental illness. METHOD: Psychiatry residents were recruited during their clinical rotations at a Canadian mental health hospital. The participants took on the first-person perspective of a geriatric patient with mental illness initially through written reflection, and then physically inhabited this role by wearing an aging simulation suit to perform the task of meeting with a pharmacist to review current medications and prepare a dosette. Concurrently, an audio file was played through headphones to simulate auditory hallucinations. A pre- and post-Jefferson Scale of Empathy (JSE), reflective writing exercise, debrief transcription, and evaluation questionnaire were used to evaluate the intervention. Interviews conducted 3 month post-intervention explored its impact on their clinical practice. RESULTS: Fifteen psychiatry residents completed the study. There was a significant increase in JSE scores pre (M = 115.5, SD = 13.2) to post (M = 119.2, SD = 12.7) intervention, t(14) = 2.65, p = .02. The qualitative findings of the study demonstrated participants' improved understanding and awareness of the patient perspective and the ability to communicate this understanding and show intentions to help through practice change. CONCLUSION: An aging suit simulation with debriefing may be an effective educational intervention to incorporate into the medical curriculum to foster empathy for this stigmatized population.

Early Clinical Exposure to Geriatric Psychiatry and Medical Students' Interest in Caring for Older Adults: A Randomized Controlled Trial.

OBJECTIVE: In the next 25 years, the population aged 65 and older will nearly double in many countries, with few new doctors wishing to care for older adults. The authors hypothesize that early clinical exposure to elderly patient care could increase student interest in caring for older adults during their future career. METHODS: The authors conducted a pragmatic medical education randomized controlled trial (RCT) at the Jewish General Hospital and the Douglas Mental Health Institute, McGill University, in Montreal, Canada. Third-year medical students undergoing their mandatory 16-week half-time clerkship rotation in psychiatry were randomly assigned to the equivalent of 2-4 weeks of full-time exposure to clinical geriatric psychiatry (n = 84). RESULTS: Being randomly assigned to geriatric psychiatry exposure (n = 44 of 84) was associated with increased "comfort in working with geriatric patients and their families" at 16-week follow-up (59.1% versus 37.5%, χ2 (1) = 3.9; p = 0.05). However, there was no significant association found between geriatric psychiatry exposure and change "in interest in caring for older adults," or change in "interest in becoming a geriatric psychiatrist." CONCLUSION: The results of this pragmatic education RCT suggest that exposing third-year medical students to 2-4 weeks of geriatric psychiatry did not increase their interest to care for older adults or become a geriatric psychiatrist. However, it did increase their comfort level in working with older adults and their families. However, more research is necessary to identify potential interventions that could inspire and increase medical student interest in caring for older adults as part of their future careers.

Using an Integrated Care Pathway for Late-Life Schizophrenia Improves Monitoring of Adverse Effects of Antipsychotics and Reduces Antipsychotic Polypharmacy.

OBJECTIVE: Antipsychotic use in older patients is associated with many adverse effects, including tardive dyskinesia and extrapyramidal symptoms, which, in turn, increase the risk of falling. Antipsychotics are also associated with metabolic syndrome and cognitive impairment in older patients. Integrated care pathways (ICPs) are designed to manage specific conditions using standardized assessments and measurement-based interventions. This study aims to compare the use of recommended tools to monitor for adverse effects associated with antipsychotics in older patients managed within an ICP and those managed under usual care conditions-i.e., treatment as usual (TAU). METHODS: We reviewed and compared the health records of 100 older patients enrolled in an ICP for late-life schizophrenia with those of 100 older patients treated with antipsychotics under TAU conditions. RESULTS: Monitoring rates were significantly higher in the ICP group than in the TAU group for all assessments: extrapyramidal symptoms (94% versus 5%), metabolic disturbances (91% versus 25%), fall risk (82% versus 35%), and cognitive impairment (72% versus 28%). Rates of antipsychotic polypharmacy were also six times higher in the TAU group. CONCLUSION: Older patients with schizophrenia treated with antipsychotics within an ICP experience higher rates of monitoring and less psychotropic polypharmacy than older patients treated with antipsychotics under TAU conditions. These findings suggest that an ICP can improve the quality of antipsychotic pharmacotherapy in older patients and thus possibly its effectiveness. This needs to be confirmed by a randomized controlled trial.

Gabapentin and pregabalin to treat aggressivity in dementia: a systematic review and illustrative case report.

AIMS: The prevalence of dementia is rising as life expectancy increases globally. Behavioural and psychological symptoms of dementia (BPSD), including agitation and aggression, are common, presenting a challenge to clinicians and caregivers. METHODS: Following PRISMA guidelines, we systematically reviewed evidence for gabapentin and pregabalin against BPSD symptoms of agitation or aggression in any dementia, using six databases (Pubmed, CINHL, PsychINFO, HealthStar, Embase, and Web of Science). Complementing this formal systematic review, an illustrative case of a patient with BPSD in mixed Alzheimer's/vascular dementia, who appeared to derive benefits in terms of symptom control and functioning from the introduction of gabapentin titrated up to 3600 mg day-1 alongside other interventions, is presented. RESULTS: Twenty-four relevant articles were identified in the systematic review. There were no randomized trials. Fifteen papers were original case series/case reports of patients treated with these compounds, encompassing 87 patients given gabapentin and six given pregabalin. In 12 of 15 papers, drug treatment was effective in the majority of cases. The remaining nine papers were solely reviews, of which two were described as systematic but predated PRISMA guidelines. Preliminary low-grade evidence based on case series and case reviews suggests possible benefit of gabapentin and pregabalin in patients with BPSD in Alzheimer's disease. These benefits cannot be confirmed until well-powered randomized controlled trials are undertaken. Evidence in frontotemporal dementia is lacking. CONCLUSION: Gabapentin and pregabalin could be considered for BPSD when medications having stronger evidence bases (risperidone, other antipsychotics, carbamazepine and citalopram) have been ineffective or present unacceptable risks of adverse outcomes.

Pharmacotherapy of major depression in late life: what is the role of new agents?

INTRODUCTION: Evidence on the pharmacotherapy of late-life major depressive disorder (LLD) is scant. Most of the recommendations in existing clinical guidelines are based on expert opinions, extrapolations from data obtained in younger patients, or theoretical considerations. Areas covered: This article summarizes the recommendations from existing clinical guidelines and recent reviews on the treatment of LLD. Next, it discusses the potential role of newer antidepressants - vilazodone, levomilnacipran, and vortioxetine - based on a systematic search of the literature published during the past five years. Then, it presents evidence pertaining to the use of ketamine, aripiprazole, brexpiprazole, quetiapine, and methylphenidate in the treatment of LLD. Expert opinion: Very few recent publications directly relevant to the pharmacotherapy of LLD were identified: there are no published data supporting the use of vilazodone, levomilnacipran, ketamine, or brexpiprazole in older patients. Recent placebo-controlled randomized controlled trials (RCTs) support the use of vortioxetine, quetiapine monotherapy, aripiprazole augmentation, or methylphenidate augmentation (with one RCT for each). Thus, overall, there have been few innovations in the pharmacotherapy of LLD over the past decade and the stepwise approach recommended in older guidelines remains relevant today. More studies addressing the relative efficacy, tolerability, and safety of psychotropic medications are needed.

Simulation in Undergraduate Psychiatry: Exploring the Depth of Learner Engagement.

OBJECTIVES: Simulation-based methodologies are increasingly used in undergraduate medical education to expand students' exposure to complex clinical scenarios. Engagement of students in these simulation-based methodologies is a key determinant of their success in learning. Thus, the authors conducted a systematic review to (1) identify simulation methods in use within the undergraduate psychiatry curriculum and (2) assess learner engagement using these methods. METHODS: Following a PRISMA methodology, the authors searched MEDLINE, ERIC, and PsychINFO databases from 1977 to 2015. Studies applying simulation in undergraduate psychiatric education were reviewed. The depth of learner engagement was assessed using Kolb's four-stage learning cycle. RESULTS: Of 371 publications identified, 63 met all the inclusion criteria: 48 used standardized patients and 16 used online or virtual learning case modules. Only one study used high fidelity mannequins. Three studies satisfied multiple stages in Kolb's Learning Cycle, including a single study that addressed all four domains. CONCLUSIONS: Despite the varied uses of simulation across other health disciplines, there were few novel or innovative uses of simulation in undergraduate psychiatric education since the last review in 2008. Expanding on the use of simulation to improve communication, build empathy, and decrease stigma in psychiatry is essential given the relevance to all facets of medical practice. Given the complexity of psychiatry, simulation interventions should extend beyond communication scenarios. Medical students need more opportunities to reflect and debrief on simulation experiences and integrate learning into new contexts. Faculty development should focus on these novel approaches to simulation to deeply engage learners and enhance outcomes.

Culture and suicide

Undefined cultural factors cannot be dismissed and significantly contribute to the worldwide incidence of death by suicide. Culture is an all embracing term and defines the relationship of an individual to his environment. This chapter seeks to investigate the effect of culture on suicide both regionally and internationally. Culture-bound syndrome with suicidal behaviours specific to a particular culture or geographical region are discussed. Opinions are divided as to the status of religious martyrs. The law itself is silent on many aspects of suicidal behaviour and despite decriminalization of suicide as self murder, the latter remains on the statues of many developing countries. The Caribbean region is of concern due to its steady rise in mean suicide rate, especially in Trinidad and Tobago where socio-cultural factors are instrumental in influencing suicidal behaviour. These include transgenerational cultural conflicts, psycho-social problems, media exposure , unemployment, social distress, religion and family structure. The methods are attributed to accessibility and lethality. Ingestion of poisonous substances is most popular followed by hanging and most recently shooting. The gender differences seen with regard to suicidality can also be attributed to gender related psychopathology and psychosocial differences in help seeking behaviour. These are influenced by the cultural environment to which the individual is exposed. Culture provides coping strategies to individuals; as civilization advances many of these coping management of suicidal behavior, a system of therapeutic re-culturation is needed with an emphasis on relevant culture-based therapies.

Consultation-liaison psychiatry in Trinidad and Tobago with reference to suicidal behavior

Consultation-liaison psychiatry (C-LP) has been defined as the area of clinical psychiatry that encompasses clinical, teaching and research activities of psychiatrist and allied mental health professionals in the non psychiatric divisions of a general hospital. Over the years, consultation-liaison services have expanded to provide care in health care facilities other than the general hospital, such a community health clinics, rehabilitation centers, convalescent hospitals, nursing homes and doctors' private offices. The term Consultation-Liaisons reflects two interrelated roles of the consultant. Consultation refers to the provision of expert diagnostic opinion and advice on management regarding a patient's mental state and behavior at the request of another health professional. Liaison refers to a linking up of groups for the purpose of effective collaboration. The present chapter reviews how these roles are addressed in Trinidad and Tobago.

Cultural aspects of suicide.

Undefined cultural factors cannot be dismissed and significantly contribute to the worldwide incidence of death by suicide. Culture is an all embracing term and defines the relationship of an individual to his environment. This study seeks to investigate the effect of culture on suicide both regionally and internationally. Culture-bound syndrome with suicidal behaviours specific to a particular culture or geographical region are discussed. Opinions are divided as to the status of religious martyrs. The law itself is silent on many aspects of suicidal behaviour and despite decriminalization of suicide as self-murder, the latter remains on the statutes of many developing countries. The Caribbean region is of concern due to its steady rise in mean suicide rate, especially in Trinidad and Tobago where socio-cultural factors are instrumental in influencing suicidal behaviour. These include transgenerational cultural conflicts, psycho-social problems, media exposure, unemployment, social distress, religion and family structure. The methods used are attributed to accessibility and lethality. Ingestion of poisonous substances is most popular followed by hanging. The gender differences seen with regard to suicidality can also be attributed to gender related psychopathology and psychosocial differences in help-seeking behaviour. These are influenced by the cultural environment to which the individual is exposed. Culture provides coping strategies to individuals; as civilization advances many of these coping mechanisms are lost unclothing the genetic predisposition of vulnerable groups. In the management of suicidal behaviour, a system of therapeutic re-culturation is needed with an emphasis on relevant culture- based therapies.