Innovative methods in teaching psychiatry to medical students

Background and Objectives: To test the conjecture that the innovative method to teach psychosomatic psychiatry previously reported will be confirmed as beneficial in the training of medical students in the field of general psychiatry. Methods: The emphasis in this course is placed on the discussion of clinical cases, bed-side clinical teaching, and a research-oriented part. The "Innovative Teaching Plan" (ITP) is intended to train student-leaders to guide small groups (SG) of students. The results of an intensive clerkship on bedside teaching are also studied. Trainee performance was assessed by the marks in the final examination, and a reliable and valid tool, the Medical Teaching Quality Questionnaire (MTQQ) was used to document trainee satisfaction. The results of five academic courses are presented in this report. Results: External experts consulted assured that the content of the course was adequate. Eight hundred and thirty eight medical students have completed the learning course in the study period, and 418 (one of the two groups) completed the evaluation with the MTQQ. Most items related to the students' satisfaction were rated "high" or "very high", including the items asking about the usefulness of the course for physicians, the quality of the teaching methods and the bedside teaching. In relation to innovation, the discussion of clinical cases in small groups was also very satisfactory and the "enhancement of a researcher's mind" was rated "high" or "very high" by 1/3rd of medical students. The utility of the yearly evaluation of the quality of teaching methods was supported by results showing that items scored not favourably in the initial evaluation were considerably improved in the follow-up evaluations, when modifications in the method were introduced. Conclusions: Good performance and high satisfaction of medical students was documented in a course on general psychiatry. Lessons may be drawn to inform about efficient and effective ways of teaching and learning this subject (AU)

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Depression and incident Alzheimer disease: the impact of disease severity.

OBJECTIVES: To test the hypothesis that clinically significant depression (particularly severe depression) increases the risk of Alzheimer's disease (AD). METHODS: A longitudinal, three-wave epidemiologic study was implemented in a sample of individuals aged 55 years and older (n = 4,803) followed up at 2.5 years and 4.5 years. This was a population-based cohort drawn from the Zaragoza Dementia and Depression (ZARADEMP) Project, in Zaragoza, Spain. Participants included individuals cognitively intact at baseline (n = 3,864). The main outcome measures were depression as assessed by using the diagnostic interview Geriatric Mental State- Automated Geriatric Examination for Computer Assisted Taxonomy package; and AD diagnosed by a panel of research psychiatrists according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. The Fine and Gray multivariate regression model was used in the analysis, accounting for mortality. RESULTS: At baseline, clinically significant depression was diagnosed in 452 participants (11.7%); of these, 16.4% had severe depression. Seventy incident cases of AD were found at follow-up. Compared with nondepressed individuals, the incidence rate of AD was significantly higher in the severely depressed subjects (incidence rate ratio: 3.59 [95% confidence interval: 1.30-9.94]). A consistent, significant association was observed between severe depression at baseline and incident AD in the multivariate model (hazard ratio: 4.30 [95% CI: 1.39-13.33]). Untreated depression was associated with incident AD in the unadjusted model; however, in the final model, this association was attenuated and nonsignificant. CONCLUSIONS: Severe depression increases the risk of AD, even after controlling for the competing risk of death.

Usefulness of 2 questions about age and year of birth in the case-finding of dementia.

OBJECTIVE: To test the hypothesis that the efficacy of 2 simple questions commonly used in clinical practice, asking the age and year of birth of individuals, will be satisfactory to rule out cases of dementia. DESIGN: Population-based, longitudinal, prospective study focused on the incidence of dementia. In the baseline, a 2-phase procedure for identifying cases and noncases of dementia was implemented. SETTING: Zaragoza, Spain. PARTICIPANTS: Individuals 65 years or older without previous diagnoses of dementia (n = 3613) drawn from the population-based random sample of the ZARADEMP project. MEASUREMENTS: Standardized instruments were used, including the Geriatric Mental State (GMS) and the History and Aetiological Schedule (HAS); cases were diagnosed according to DSM-IV criteria ("reference standard"). The simple cognitive test used in this study consists of the following 2 compulsory questions: "How old are you?" and "What year were you born?" RESULTS: The test was well accepted by the participants and took less than 30 seconds to complete. Compared with the "reference standard," validity coefficients for incorrect answers in both questions were as follows: sensitivity 61.2%, specificity 97.8%, positive predictive value 44.4%, negative predictive value 98.9%. CONCLUSIONS: This ultra-short test has very good specificity and negative predictive power. Its use to rule out cases of dementia might be generalized, as it has the best efficiency reported to date.

The teaching of liaison psychiatry.

OBJECTIVE: To document performance and satisfaction of medical students in a short course on liaison psychiatry. METHODS: The emphasis in this optional course is placed on the discussion of clinical cases, bed-side clinical teaching, and a research-oriented part. The "Innovative Teaching Plan" (ITP) is intended to train student-leaders to guide small groups (SG) of students. Trainee performance was assessed by the marks in the final examination, and a reliable and valid tool, the Medical Teaching Quality Questionnaire (MTQQ) was used to document trainee satisfaction. The results of four academic courses are presented in this report. RESULTS: External experts consulted assured that the content of the course was adequate. It has been completed by more than 200 medical students, and high marks have been obtained by most. Above average scores (AA, "high" or "very high") were given by substantial proportions of students in most items, related to the "relevance" of the subject, the "usefulness of the clinical cases" or the "enhancement of student-teacher interaction". Compared to the first academic course, students' satisfaction has improved. "Enhancement of a researcher's mind" was rated AA by 61.1% of students in the last academic course, and "global satisfaction" by 88.8%. CONCLUSIONS: Good performance and high satisfaction of medical students was documented in a course on liaison psychiatry. Lessons may be drawn to inform about efficient and effective ways of teaching and learning this subject.

[Background and findings of neuroimaging in schizophrenia: an update]. / Fundamentos y hallazgos de la neuroimagen en la esquizofrenia: una actualización.

INTRODUCTION: Neuroimaging of psychiatric disorders, especially on schizophrenia, has been increased in the last decade. Different brain imaging techniques have become a useful tool to discover the pathophysiology of schizophrenia. AIMS: To describe scientific and historical background of neuroimaging in psychiatry, and to describe the current structural, functional and neurochemical findings in schizophrenia using brain imaging techniques, and their potential disadvantages. DEVELOPMENT: This review synthesizes our current knowledge on the neurobiology of psychosis, reviewing studies including structural (magnetic resonance imaging, diffusion tensor imaging), functional (PET and SPECT, functional magnetic resonance imaging) and neurochemical/transmission (neurochemical PET and SPECT, magnetic resonance spectroscopy) neuroimaging techniques on schizophrenia. CONCLUSIONS: Cognitive impairment, structural and functional disturbances, dopaminergic hypothesis, white matter changes, and any other findings, have been reported. Nevertheless, there are still many doubts and discrepancies to solve, regarding to neuroimaging in schizophrenia. Coupling multimodal imaging with genetics and pharmacotherapeutic studies will further assist in understanding the pathophysiology of schizophrenia.

Fundamentos y hallazgos de la neuroimagen en la esquizofrenia: una actualización / Background and findings of neuroimaging in schizophrenia: an update

Introducción. La neuroimagen de los trastornos psiquiátricos, y en especial de la esquizofrenia, se ha incrementado en la última década. Las distintas modalidades de imagen cerebral se han convertido en una valiosa herramienta para investigar la fisiopatología de la esquizofrenia. Objetivos. Presentar los fundamentos científicos e históricos de la investigación con neuroimagen en psiquiatría y documentar los hallazgos estructurales, funcionales y bioquímicos de la esquizofrenia obtenidos mediante técnicas de neuroimagen, así como las posibles limitaciones que éstas presentan. Desarrollo. Este trabajo sintetiza el conocimiento actual de la neurobiología de la psicosis, mediante la revisión de estudios que incluyen técnicas de neuroimagen estructurales –resonancia magnética, imagen mediante tensor de difusión–, funcionales –tomografía computarizada por emisión de fotón único (SPECT) y tomografía por emisión de positrones (PET) de perfusión, resonancia magnética funcional– y bioquímicas o de transmisión –PET y SPECT de transmisión, espectroscopia por resonancia magnética– en la esquizofrenia. Conclusiones. Los estudios han confirmado los déficit cognitivos, las alteraciones estructurales y funcionales, la hipótesis dopaminérgica y las alteraciones en la sustancia blanca, entre otros muchos hallazgos; sin embargo, todavía quedan muchas dudas y discrepancias por resolver en cuanto a los hallazgos de la neuroimagen en la esquizofrenia. Ensamblar distintas técnicas de neuroimagen con estudios de genética y farmacoterapia permitiría obtener un conocimiento más amplio de la fisiopatología de la esquizofrenia (AU)

Introduction. Neuroimaging of psychiatric disorders, especially on schizophrenia, has been increased in the last decade. Different brain imaging techniques have become a useful tool to discover the pathophysiology of schizophrenia. Aims. To describe scientific and historical background of neuroimaging in psychiatry, and to describe the current structural, functional and neurochemical findings in schizophrenia using brain imaging techniques, and their potential disadvantages. Development. This review synthesizes our current knowledge on the neurobiology of psychosis, reviewing studies including structural (magnetic resonance imaging, diffusion tensor imaging), functional (PET and SPECT, functional magnetic resonance imaging) and neurochemical/transmission (neurochemical PET and SPECT, magnetic resonance spectroscopy) neuroimaging techniques on schizophrenia. Conclusions. Cognitive impairment, structural and functional disturbances, dopaminergic hypothesis, white matter changes, and any other findings, have been reported. Nevertheless, there are still many doubts and discrepancies to solve, regarding to neuroimaging in schizophrenia. Coupling multimodal imaging with genetics and pharmacotherapeutic studies will further assist in understanding the pathophysiology of schizophrenia (AU)

Diabetes and depression.

In a context of the potentially epidemic nature of both diabetes mellitus and depression, and the negative effects reported in cases of comorbidity, this review suggests that the association of the two conditions is multifaceted. Increased risks of prevalent depression and incident depression among diabetic patients have been reported in community studies. Even more consistent is the finding supporting psychosomatic hypotheses regarding the increased risk of diabetes among depressed patients. A recent relevant finding is the increased risk of diabetes reported in depression that is commonly found in the community, namely nonsevere, persistent, untreated depression. In view of the negative implications of the comorbidity of depression and diabetes, the suggestion that all clinically relevant cases of depression found in the community should be treated seems logical. However, new studies seem mandatory to document the efficacy of treatment of depression and the safety of antidepressant use in cases of comorbidity.

Depressive disorder and incident diabetes mellitus: the effect of characteristics of depression.

OBJECTIVE: The purpose of this study was to test the hypothesis that clinically significant depression detected in a population sample increases the risk of diabetes mellitus. The authors examined the effect of characteristics of depression frequently found in the community on the risk of incident diabetes mellitus. METHOD: A large community sample of adults aged > or = 55 years (N=4,803) was assessed at baseline in a longitudinal three-wave epidemiological enquiry using a psychiatric interview and the Geriatric Mental State Schedule. Cases of depression were diagnosed according to standardized criteria, and diabetes was assessed using a risk factors questionnaire. Follow-up evaluations, conducted 2.5 and 5 years later, were completed to determine the incidence of diabetes. RESULTS: At baseline, 379 case subjects with depression were identified. The risk of incident diabetes mellitus was higher among subjects with depression when compared with nondepressed subjects, and the association remained significant after controlling for potential confounders, including diabetes risk factors. The estimated rate of diabetes mellitus attributable to depression was 6.87%. An increased risk of diabetes mellitus was also associated with the following characteristics of depression: nonsevere depression, persistent depression, and untreated depression. Treatment with antidepressants was not associated with an increased risk of diabetes mellitus. CONCLUSIONS: Clinically significant depression is associated with a 65% increased risk of diabetes mellitus. Characteristics of depression frequently found in the community, namely nonsevere depression, persistent depression, and untreated depression, may play a role in the development of diabetes in a predominantly elderly adult population.

A new autopsy interview for the assessment of factors potentially related to death in depressed medical patients.

This study tests the reliability and validity of the Bio-Psycho-Social Autopsy (BPSA), a new interview to assess physical, psychopathological, and social factors potentially related to mortality in depressed medical patients. The authors completed special procedures to provide support for the face and content validity of the interview. They built the psychopathological and social sections on the Standardized Polyvalent Psychiatric Interview (SPPI) but gave self-neglect special emphasis. They tested the BPSA on close relatives of 48 deceased patients, both depressed and nondepressed. They calculated interrater reliability coefficients and took preliminary steps to document the construct validity by means of epidemiological and clinical variables. Interrater reliability coefficients were acceptable (M kappa = 0.82). In support of the construct validity, a multivariate analysis showed that BPSA items in the psychopathological section were able to differentiate the expected direction between deceased patients who were depressed and nondepressed. Therefore, the authors considered the BPSA interview to be a reliable assessment of factors potentially associated with death in depressed medical patients, and data presented support the validity of the psychopathological section.

Non-cognitive psychopathological symptoms associated with incident mild cognitive impairment and dementia, Alzheimer's type.

OBJECTIVE: To test the hypothesis that specific psychopathological non-cognitive symptoms are associated with incident mild cognitive impairment (MCI), while different symptoms are associated with incident dementia of Alzheimer's type (DAT). METHODS: A representative community sample of 4,803 individuals aged 55+ years was interviewed in a two-phase screening, in Wave I or ZARADEMP I. This is the baseline, cross-sectional study of the ZARADEMP Project, a longitudinal study to document incidence and risk factors of dementia. The main instrument for assessment of participants was the ZARADEMP Interview, which includes standardized Spanish versions of instruments such as the Mini-Mental Status Examination and the Geriatric Mental State GMS-AGECAT. Two years later, in Wave II or ZARADEMP II, the cognitively non-deteriorated elderly were reassessed in a similar, two-phase procedure. "Incident cases" of both dementia and DAT (DSM-IV-TR criteria), as well as MCI (operationally defined Petersen's criteria) were diagnosed by a panel of psychiatrists. Statistical, logistic regression models, adjusted by age, sex and education were used to test the hypothesized association. RESULTS: "Irritability", "neurovegetative symptoms", "sleep problems", "concentration difficulties", "loneliness" and "subjective slowing" documented at baseline were associated with incident MCI (odds ratio, OR range 1.71-2.67). A different profile of non-cognitive symptoms was associated with incident DAT, specifically "tension" (OR= 2.45), "sleep problems" (OR= 2.81), and "observed slowing" (OR= 4.35). On the contrary, "subjective restriction of activities" seemed to be negatively associated with DAT (OR= 0.12). CONCLUSIONS: To our knowledge, this is the first report about some specific psychopathological, non-cognitive symptoms associated with incident MCI and/ or incident DAT, when controlling by each other. The psychopathological profile associated with MCI is different from the profile preceding DAT.

Somatic and psychiatric comorbidity in the general elderly population: results from the ZARADEMP Project.

OBJECTIVE: In a representative sample of the elderly population in a southern European city, we tested the hypothesis that there is an association between general somatic and general psychiatric morbidity. METHODS: A stratified random sample of 4803 individuals aged > or =55 years was selected for the baseline study in the ZARADEMP Project. The elderly were assessed with standardized Spanish versions of instruments, including the Geriatric Mental State (GMS)-AGECAT. Psychiatric cases were diagnosed according to GMS-AGECAT criteria, and somatic morbidity was documented with the EURODEM Risk Factors Questionnaire. RESULTS: General comorbidity clustered in 19.9% of the elderly when hypertension was removed from the somatic conditions category, with 33.5% of the sample remaining free from both somatic and psychiatric illnesses. General comorbidity was associated with age, female gender, and limited education, but did not increase systematically with age. The frequency of psychiatric illness was higher among the somatic cases than among noncases, and the frequency of somatic morbidity among the psychiatric cases was higher than among noncases. This association between somatic and psychiatric morbidity remained statistically significant after controlling for age, gender, and education [odds ratio (OR)=1.61; confidence interval (CI)=1.38-1.88]. Most somatic categories were associated with psychiatric illness, but after adjusting for demographic variables and individual somatic illnesses, the association remained statistically significant only for cerebrovascular accidents (CVAs) (OR=1.47; CI=1.09-1.98) and thyroid disease (OR=1.67; CI=1.10-2.54). CONCLUSION: This is the first study to document that there is a positive and statistically significant association between general somatic morbidity and general psychiatric morbidity in the (predominantly) elderly population. CVAs and thyroid disease may have more weight in this association.

Propiedades psicométricas de una encuesta de evaluación para el área docente de psiquiatría / Psychometric properties of a teaching evaluation questionnaire for an Academic Psychiatric Area

Introducción: La aplicación de los estándares internacionales de calidad en los estudios de Medicina es necesario en el contexto del actual proceso de Convergencia al Espacio Europeo de Educación Superior (CEEES) en Ciencias de la Salud; de ello se deriva la importancia de la mejora de la calidad docente. El empleo de cuestionarios es una de las herramientas más empleadas para evaluar la calidad de la docencia. El objetivo principal de esta publicación es presentar las propiedades psicométricas de fiabilidad y validez de una encuesta desarrollada para evaluar las asignaturas del Área de Psiquiatría de la Facultad de Medicina de Zaragoza. Material y Métodos: Durante el curso académico (..) (AU)

Introduction: In the context of the process to establish the European Higher Education Area (EHEA), the implementation of international quality standards in Medical Education is essential; and the improvement of teaching effectiveness is therefore of great importance. Students' rating questionnaires are the teaching evaluation tool in most widespread use. The main objective of this study is to present psychometric properties, such as reliability and validity, of a questionnaire developed for the assessment of subjects in the Psychiatry Department of the Faculty of Medicine in Zaragoza. Methods: Students attending the last two Psychosomatics and Consultation-Liaison Psychiatry classes in 2005-2006, were invited to fill out a confidential questionnaire designed by the authors. Test-retest reliability, internal consistency and content validity were tested, and an approximation to construct validity was also approached. Results: Cronbach’s a coefficient was 0.865 (good to excellent according to the standard) and test-retest kappaW was 0.655 (C.I. 99% .562-.748). Feasibility was appropriate and data about correlation of measures of satisfaction and the outcome of teaching support the construct validity of the questionnaire. Conclusions: The feasibility and reliability of the new scale for medical students evaluation is documented, and preliminary data support its construct validity. It is suggested that the new tool may be useful in deciding about teaching methods in the Area of Psychiatry. Furthermore, its usefulness might be extended to other Biomedical Areas (AU)

Aggressive behavior in patients with stroke: association with psychopathology and results of antidepressant treatment on aggression.

OBJECTIVE: To examine, in a post hoc analysis of an antidepressant treatment trial, correlates of irritability and aggression after stroke and changes in irritability scores associated with antidepressant treatment. DESIGN: Aggressive patients (n=23) were compared with nonaggressive patients (n=69) on numerous measures of psychopathology, poststroke impairment, and neuroimaging findings. SETTING: All patients were hospitalized at the time of the initial evaluation for acute stroke or for rehabilitation therapy. PARTICIPANTS: Ninety-two patients from the Iowa City Stroke Study were classified as aggressive or nonaggressive, based on symptoms elicited by the Present State Examination (PSE) and from family or caretaker reports. INTERVENTION: All patients were randomized to receive nortriptyline, fluoxetine, or placebo using a double-blind methodology. MAIN OUTCOME MEASURE: The change in aggression score as elicited by the PSE at the beginning and the end of a 12-week treatment trial. RESULTS: Twenty-five percent (23/92) of patients reported irritability or aggression. Irritable and aggressive patients had higher total PSE scores, Hamilton Depression Rating Scale scores, Hamilton Anxiety Rating Scale (HAMA) scores, and lower Mini-Mental State Examination scores. They also had lesions that were more proximal to the frontal pole. Stepwise regression analysis showed that HAMA scores and proximity of lesion to the frontal pole were significant independent predictors of irritability. Among irritable and aggressive patients with depression who responded to antidepressants, there was a significantly greater reduction in irritability after treatment, compared with patients whose depression did not lessen with treatment. CONCLUSIONS: Several factors, such as severity of impairment, other psychopathology, and neurobiologic factors, appear to contribute to irritable and aggressive behavior in stroke patients. If depression accompanies aggression, the results of this small study suggest that successful treatment of depression may reduce aggressive behavior.

“Depressive co-morbidity in medical in-patients at the time of hospital discharge and outcome in a Primary Care follow-up. I. Rational and design of the project”

Objectives: In a context of a “continuity of care” model in Psychosomatic and Liaison Psychiatry, this study is intended to test, in patients to be discharged from Medicine wards, hypotheses related to a high prevalence of depression and, in particular, its negative outcome at six-months follow-up in Primary Care (PC), especially among the elderly. Methods: Sample. Consecutive patients aged 18 years or more, hospitalized in Medicine wards were randomly selected for screening at the time of admission. On the bases of a previous study and the expected sampling errors, sample size was estimated in 700patients (approximately 60% in geriatric age) for the initial screening, to recruit 75 or more cases of depression and enough number of control, non-cases without psychiatric morbidity..Instruments. Standardized, Spanish versions of screening/case-finding instruments COMPRI/INTERMED, Mini-Mental, CAGE and drug screening, Hospital Anxiety and Depression Scale (HADS), Standardized Polyvalent Psychiatric Interview (SPPI). Diagnostic criteria ICD-10 research, medical patients version and DSM-IV-TR (psychiatric);and ICD-9-M; ICHPPC, WONCA (medical). Cumulative Illness Rating Scale (CIRS)(severity of physical condition); SF36 and EuroQol (quality of life); Client Service Receipt Interview (CSRI) (costs).Procedure. Part I, hospital study: Two-phase screening (lay interviewers: COMPRI/INTERMED at admission; Mini-Mental, CAGE, HADS at the time of discharge; and standardized clinicians: SPPI). CIRS was used to control severity of physical conditions. Part II, follow-up study in PC (six months): Standardized clinicians, blind to the previous phases (HADS and SPPI to both cases and controls). Outcome study: Euro-Quol, SF36, CSRI and data on morbidity and mortality, were collected. Conclusions. To our knowledge, this is the first study using modern epidemiological methods in medical patients to be discharged with co-morbid depression and followed in PC with a “continuity of care” strategy. The final analysis of data should support the design of an evidence-based, intervention study on co-morbid depression (AU)