A Survey of Psychiatry Course Offerings for Fourth-Year Medical Students.

OBJECTIVE: Fourth-year course offerings seem to vary widely among psychiatry departments with some offering a wide selection while others offer little or unspecified opportunity. The purpose of this study was to learn the distribution and diversity of fourth-year medical school psychiatry courses and identify unique course offerings that may inspire other departments. METHODS: The authors compiled a list of US allopathic medical schools accredited by the Liaison Committee on Medical Education (LCME) using the LCME website. They accessed each school's website catalog and recorded all psychiatry electives available to fourth-year students listed in the catalog or the Visiting Student Application Service® (VSAS®) database. The authors calculated median published course offerings per department and categorized each course according to learning opportunity. RESULTS: The authors identified 142 fully accredited allopathic medical schools of which n = 126 listed fourth-year medical student courses on their website or through VSAS. The median number of fourth-year psychiatry course offerings per school was 6 (range, 1-22). The most frequently offered courses were inpatient psychiatry (n = 105 schools), child and adolescent psychiatry (n = 95), and consultation psychiatry (n = 84). The authors also identified unique enrichment courses in media, women's health, ethics, research, and cultural psychiatry. CONCLUSIONS: The fourth-year curriculum varies widely among institutions. Hypotheses to be tested are if prioritizing robust fourth-year rotations include improved resident readiness, improved retention of home students into the training program, improved recruitment of visiting students, increased faculty scholarly activity and career development, and improved recruitment into the subspecialties.

Decisional Capacity and Personality Disorders: Substantially Unable or Substantially Unwilling?

Capacity assessments are performed when there is suspicion that a person is unable to adequately care for their physical, medical, or financial well-being. The purpose of these assessments is to inform the legal system as to whether or not guardianship may be necessary. It is well established that certain mental illnesses, such as neurocognitive disorders (dementia) or psychotic disorders (like schizophrenia), may diminish capacity and, in some cases, lead to the need for establishment of a legal guardian. However, personality disorders are another common category of mental illness which may impair decision-making. There is very little information in the literature about how or why these disorders could impair capacity, and thus, it can often be difficult to discern whether clients with personality disorders are substantially unable to care for themselves-versus unwilling to act in a way contrary to their ingrained habits. We present a series of three cases in which clients are determined to lack capacity primarily mediated by a personality disorder diagnosis. They are demonstrated to have mild deficits in cognitive functioning, but they show impaired decision-making out of proportion to these deficits. In all three cases, it is apparent that the personality disorder is substantially impairing their ability to care for themselves. Discussion includes consideration for ways to incorporate evaluations of cognitive function, activities of daily living, and personality considerations into capacity assessments, and how to approach recommendations (such as guardianship vs. less restrictive option) based on both level and scope of impairment.

Hallucinogens and Their Therapeutic Use: A Literature Review.

The exploration of possible therapeutic benefits of hallucinogenic substances has undergone a revitalization in the past decade. This literature review investigated the published literature regarding the psychotherapeutic uses of hallucinogens in psychiatric disorders. The results showed that a variety of substances have been evaluated in the treatment of psychiatric disorders, including ayahuasca, ibogaine, ketamine, lysergic acid diethylamide, 3,4-methylenedioxymethamphetamine, and psilocybin. The conditions treated ranged from depression to autism, with the largest volume of research dedicated to substance use disorders. The majority of studies that were reviewed demonstrated significant associations with improvement in the conditions investigated. However, it was difficult to draw definitive conclusions as most studies suffered from small sample sizes, inconsistent measures, and poor study design. To properly assess the risks and potential benefits of hallucinogens in psychiatric treatment, there is a need for well designed, standardized studies that demonstrate the impact of hallucinogenic substances on psychiatric conditions.

Development of Evaluations to Assess the Quality of Residency Program Directors.

OBJECTIVE: The objective was to develop residency program director specific evaluation tools with face validity for identifying areas of excellence and opportunities for improvement. METHODS: Investigators conducted standardized interviews with graduate medical education (GME) leadership, department chairs, program directors, and senior residents assessing their perspectives on the desirable qualities of program directors. Responses were categorized by theme to create benchmarked evaluation tools. RESULTS: Residents and faculty emphasized communication, mentorship, and role modeling. Faculty emphasized maintenance of accreditation and resident discipline, while residents emphasized wellness, approachability, and maintenance of the learning environment. The investigators then developed a 10-item assessment for residents and a similar 12-item assessment for department chairs and GME leadership with face validity. CONCLUSION: Although the responsibilities of residency training directors are numerous and variable by specialty, the investigators were able to develop valid program director evaluation tool templates that can highlight the successes and opportunities for improvement of these academicians.

Postpartum depression in adolescent mothers.

BACKGROUND: Postpartum depression has been extensively studied in adults but is less understood in adolescent mothers, despite a prevalence that is double that observed in adult mothers. The purpose of this review was to describe the epidemiology, risk factors, treatment and prognosis for adolescents with postpartum depression. We also sought to identify limitations of the available literature and propose areas for future study targeting postpartum depression in this vulnerable population. METHODS: A Medline literature search was conducted for articles published between 1996 and 2015. We identified relevant studies by combining the indexed search terms 'pregnancy in adolescence or teenage pregnancy' and 'depression or postpartum depression'. Additional studies were identified from references of selected articles. We limited our search results to adolescents (18 years or younger) and English language publications. Case studies/series and editorials were excluded. RESULTS: The Medline database search identified 134 articles of which 57 met inclusion criteria. Ten additional articles were identified from reference lists yielding a total of n = 67 articles for review. Among the articles selected, 10 described epidemiology, 27 identified risk factors, nine measured long-term outcome and 21 proposed treatment strategies for postpartum depression in adolescent mothers. CONCLUSIONS: There is limited literature addressing adolescent postpartum depression, but there has been a significant growth of interest in recent years. There is a need for more randomized control trials to establish gold standards for assessing postpartum depression in adolescent mothers and standards for treatment in these patients.

Neurobiological Mediators of Squalor-dwelling Behavior.

Squalor-dwelling behavior has been characterized as living in conditions so unsanitary that feelings of revulsion are elicited among visitors. This behavior is commonly associated with an insensitivity to distress/disgust and a failure to understand the direness of one's living situation, which leads to social isolation and impairment in quality of life. Etiologically, several associations have been described in the literature, including age-related decline, lower socioeconomic status, and rural dwelling status. Primary neuropsychiatric disorders, such as psychosis, alcoholism, dementia, personality disorders, developmental delays, and learning or physical disabilities are frequently seen in squalor-dwelling individuals. However, none of these disorders seems to be necessary or sufficient to explain the behavior. Neurobiologically, squalor-dwelling behavior has been associated with frontal lobe dysfunction as evidenced by executive dysfunction; however, cognitive impairments also fail to completely explain this behavior. The purpose of this report is to describe a typical case of squalor-dwelling behavior and use it as an example to illustrate the complexity of uncovering the neurobiological basis for this maladaptive personal and public health threat. Neuroimaging findings from our case and a review of the literature point toward decreased activity in the insular cortex and the amygdala as a unifying biological explanation for squalor-dwelling behaviors.

Clock Copying Predicts Mortality in Adult Protective Services Clients.

OBJECTIVE: The objective of this study was to determine if a clock copying task predicts 18-month mortality in an Adult Protective Services (APS) sample referred for a decision-making capacity assessment. METHODS: The authors performed a retrospective medical record review of clients (N = 233) referred by APS for a decision-making capacity assessment during a 3-year time period. Information extracted included demographic data and neuropsychological performance on a battery sensitive to executive function, visuospatial ability, depression, memory, and general cognition. A Cox proportional hazards models was constructed to determine the relationship between Executive Clock Drawing Task Part 2 (CLOX2) performance and survival. RESULTS: Poor clock copying, as measured by CLOX2, predicted 18-month mortality when covaried for age, education, sex, rural dwelling status, depression, and general cognition. CONCLUSIONS: Clock copying is an easily administered visuospatial task that may inform survival in this vulnerable population.

The Best of Both Worlds: Psychiatry Training at Combined Civilian-Military Programs.

Air Force psychiatry faces the task of training competent military psychiatrists in an era of continuing reductions. Beginning in the 1980s, the Air Force started collaborating with University partners to create hybrid training programs, civilian-military psychiatry residencies. These mergers provide stability for Air Force psychiatry training in the face of increased operational missions and uncertain military recruiting. As a result of these combined programs, Air Force psychiatry residents gain access to a broader range of civilian clinical experience and expertise while maintaining a focus on distinctive military requirements. The combining of programs opens up options for academic activities which may not have otherwise existed. Both military and civilian residents benefit from the occupational psychiatry experiences available within military clinical sites. These programs give civilian residents a chance to assist active duty members and their families and provide insight into the military "lifecycle." These collaborations benefit the universities by providing access to a larger pool of residents and faculty. The synthesis of the military and civilian programs raises some ongoing obstacles such as civilian residents' ability to gain access to military resources. The programs must also accommodate separate mechanisms for selecting residents (the National Residency Matching Program versus the Joint Selection Board for Graduate Medical Education). Military residents must also comply with military standards and requirements while maintaining the universities' standards of conduct and professionalism. Merging military training programs into university programs creates a vibrant opportunity to create exceptional military and civilian psychiatrists.

Cognitive profiles of elder adult protective services clients living in squalor.

The purpose of this study was to determine whether squalor-dwelling Adult Protective Services (APS) clients were more cognitively impaired than non-squalor-dwelling APS clients referred for decision-making capacity assessments. The authors performed a retrospective medical record review of neuropsychological and demographic data gathered during decisional capacity assessments. Squalor dwelling was defined by unsanitary living conditions that posed a danger to the occupant's health or safety. Mean neuropsychological test scores were compared between squalor-dwelling (n = 50) and non-squalor-dwelling (n = 180) subjects. Squalor-dwelling clients were significantly younger than non-squalor-dwelling clients. There were no distribution differences among gender, education, race, or rural-dwelling status. Although both groups performed poorly on each neuropsychological measure, squalor dwellers demonstrated better memory and general cognitive performance. Cognition, depression, gender, race, education, dementia diagnosis, and rural-dwelling status seem insufficient to explain squalor-dwelling behaviors. Other biological and psychosocial variables should be considered.

Quantifying publication scholarly activity of psychiatry residency training directors.

OBJECTIVE: The authors quantify the number of PubMed-indexed publications by psychiatry program directors during a 5-year observation period. METHODS: The authors obtained the names of general adult, child and adolescent, and geriatric psychiatry program directors from the ACGME website and entered them into a PubMed.gov database search. Then, they counted the number of indexed publications from July 2008 to June 2013 and categorized them by academic year. RESULTS: The median number of publications was one for adult psychiatry program directors (n=184), one for child and adolescent directors (n=121), and three for geriatric psychiatry directors (n=58). CONCLUSIONS: The number of PubMed-indexed publications for program directors of general adult, child and adolescent, and geriatric psychiatry residencies is relatively low. Further research is needed to identify and examine the challenges facing program directors that may limit their ability to participate in this form of scholarly activity.

Executive function impairment and recidivism in adult protective services clients referred for a decision making capacity assessment.

The objective of this study was to determine if recidivistic Adult Protective Services (APS) cases referred for a decision-making capacity assessment were more cognitively impaired than nonrecidivistic cases. A retrospective medical record review of neuropsychological and demographic data was gathered during decisional capacity assessments. Recidivistic clients were those referred to APS more than once; those with a single open case were nonrecidivistic. Mean neuropsychological test scores were compared between recidivistic (n = 138) and nonrecidivistic (n = 95) subjects. No significant differences were found for age, gender, ethnicity, education, or dwelling status. Both recidivistic and nonrecidivistic cases performed poorly in all cognitive domains. Recidivistic clients performed significantly worse on measures of executive function (CLOX1, EXIT25). Executive function impairments seem to be one risk factor for recidivism in APS referrals. With 60% of cases referred for decision capacity assessments being recidivistic, identifying risk factors may help identify when targeted interventions are indicated to preclude recurrence of abuse.

Informing evidence-based practice: a review of research analyzing adult protective services data.

The mission of Adult Protective Services (APS) is to protect older and vulnerable adults from abuse, neglect, and exploitation. The complexity of APS cases and the potential for life-changing interventions point to the need for research that examines and evaluates APS practices. A literature review identified 50 studies published during a 16-year period that used APS agencies, clients, data, or resources to test hypotheses regarding elder abuse. The analysis revealed promising efforts toward knowledge development about elder mistreatment and self-neglect. This article provides an overview of salient findings, notes the scarcity of studies that analyze the effectiveness of APS, and highlights the need for additional research. Lessons learned are described, and APS practitioners and researchers are urged to work collaboratively to develop key practice-related questions about APS processes and outcomes that can be tested with appropriate research methodologies.

Prazosin for military combat-related PTSD nightmares: a critical review.

Military combat is a common trauma experience associated with posttraumatic stress disorder (PTSD). Trauma-related nightmares are a hallmark symptom of PTSD. They can be resistant to label-pharmacological PTSD treatment, and they are associated with a variety of adverse health outcomes. The purpose of this article is to review and evaluate prazosin therapy for combat-related PTSD nightmares. Consistent with available literature for all-causes PTSD nightmares, prazosin is an effective off-label option for combat-related PTSD nightmares. Future trials may further instruct use in specific combat-exposure profiles.

The Women's Health Objective Structured Clinical Exam: a multidisciplinary collaboration.

PURPOSE: To determine the preliminary benefits of a Women's Health Objective Structured Clinical Exam (OSCE) which integrates psychiatry and obstetrics and gynecology principles into communication-focused doctor-patient paradigms. METHOD: The authors extracted medical student survey data from pre- and post-OSCE program evaluations (n = 193). Using McNemar's tests, the authors compared pre- and post-OSCE proportions of students reporting comfort levels with interactions involving terminally diagnosed patients, domestic violence, breast feeding, and other areas relevant to women's health. RESULTS: The proportion of students reporting comfort with each communication domain increased between pre- and post-OSCE assessments. The greatest improvements were observed for discussions related to domestic violence (41% gain), terminal illness (37% gain) and postpartum depression/psychosis (23% gain). Ninety-four percent felt that this Women's Health OSCE was a valuable learning experience. CONCLUSION: The authors conclude that this Women's Health OSCE was a successful addition to the medical student clinical curriculum as measured by student satisfaction and self-reported improved comfort levels with challenging communication paradigms. Future studies will investigate the effect that this learning activity has on competency.

Neuropsychological correlates of performance based functional status in elder adult protective services referrals for capacity assessments.

We have previously described high rates of executive function impairment in clients referred by Adult Protective Services (APS) to geriatric psychiatry for decision-making capacity assessments. The purpose of this study was to determine the independent relationship between neuropsychological screening instruments, particularly instruments sensitive to executive function, and performance-based functional tasks in elder referrals. Our retrospective medical review (n = 75/157 referrals completed all neuropsychological and functional assessments) revealed that only the Executive Interview (EXIT25) contributed independent variance to money management performance (R(2) = 0.29, p < 0.001), telephone use ability (R(2) = 0.39, p < 0.001), and summed performance (R(2) = 0.45, p < 0.001). Executive instruments may specifically inform decision-making capacity assessments.

Academic performance in the context of a "three excused absences" psychiatry clerkship policy.

OBJECTIVE: In order to better manage medical student absences during the psychiatry clerkship, a policy allowing students to miss up to 3 days without penalty was developed. The purpose of this study was to describe absence patterns and compare academic performance between students with and without absences. METHOD: Authors reviewed the academic record of 3rd-year medical students rotating through the psychiatry clerkship between July 1, 2009 and June 30, 2011. The number of clerkship absences during the 6-week rotation, NBME shelf performance, and clinical evaluation scores were extracted. The sample was dichotomized into "absent" and "non-absent" groupings, and mean NBME shelf exam and subjective grades were compared by Student's t-test. RESULTS: During this period of observation, 249 students (57.5%) had no absences; 96 (22.1%) had one absence; 62 (14.3%) had two absences; 25 (5.8%) had three absences; and 1 (0.2%) had four absences. Students with no absences had higher mean NBME psychiatry shelf exam scores than students with ≥1 absences. Mean clinical grades, which include a professionalism component, and final course letter grade distribution did not differ significantly between absent and non-absent students. CONCLUSION: Given that students with absences seemed as academically successful as students who were not absent, we conclude that this policy may effectively manage commonly-expressed attendance concerns.

Improving student comfort with death and dying discussions through facilitated family encounters.

OBJECTIVE: The purpose of this study was to explore the educational potential for a collaboration between palliative medicine and psychiatry designed to improve first-year medical students' knowledge and comfort with end-of-life issues through a facilitated small-group discussion with family members of recently-deceased loved ones. METHODS: A group of 222 first-year medical students were divided into 14 small groups. Each group also consisted of two mental-health providers, one palliative-medicine interdisciplinary team member, and one family member of a recently-deceased hospice patient. A death-and-dying discussion between students and family members was facilitated by the mental-health and palliative-medicine faculty and was followed by post-activity evaluations. RESULTS: As a result of the facilitated activity, 77% of participants reported increased comfort levels and 85% reported improved knowledge of end-of-life issues. Students reporting benefit were more likely to perceive higher facilitator and family comfort levels with end-of-life discussions, better activity organization, and utility of post-encounter group discussion. CONCLUSIONS: Facilitated conversations between students and family members of recently-deceased loved ones may improve comfort and knowledge with end-of-life conversations. Future studies should explore the longer-range impact of this educational activity.

Documented combat-related mental health problems in military noncombatants.

Although combat-related posttraumatic stress disorder (PTSD) has been documented for military combatants, little is known about PTSD in noncombatants. Active-duty U.S. Air Force noncombatants (N = 5,367) completed a Post-Deployment Health Assessment upon return from combat zones in Iraq (n = 4,408) or a noncombat zone in Qatar (n = 959). Those deployed to Iraq were significantly more likely to report exposure to someone who was wounded or killed (20.8% vs. 6.3%), feeling in great danger of being killed at some point during deployment (18.9% vs. 3.5%), symptoms of PTSD (4.1% vs. 0.7%), and symptoms of major depression (9.9% vs. 5.4%). These findings suggest that deployment to a war zone is associated with increased mental health problems, even for noncombatants.

Executive clock drawing correlates with performance-based functional status in people with combat-related mild traumatic brain injury and comorbid posttraumatic stress disorder.

Executive Clock Drawing Tasks (CLOX parts 1 and 2) can predict functional impairment. This study determined the correlation between CLOX and other psychometric screening instruments with the Structured Assessment of Independent Living Skills (SAILS)-defined performance-based functional status in people with combat-related mild traumatic brain injury (TBI) and comorbid posttraumatic stress disorder (PTSD). We hypothesized that CLOX would correlate significantly with functional performance. This prospective, cross-sectional study design determined the correlation between a structured neuropsychological battery and functional status assessment. We calculated Pearson correlation coefficients between neuropsychological instruments and functional status scores. We entered neuropsychological measures correlating p < 0.1 with functional status into a linear regression model to determine independent contributions. Fifteen Operation Iraqi Freedom veterans participated. Only CLOX1 correlated significantly with functional competency and efficiency. Only mean CLOX1 scores were significantly lower in those scoring below the median for SAILS competency and in those scoring above the median for SAILS efficiency. CLOX1 contributed significant variance to functional status independent of mood or anxiety symptoms and was not affected by age or time since injury. Executive dysfunction per the brief, easily administered CLOX1 is sensitive to functional status following combat-related mild TBI, independent of PTSD anxiety with or without depression.

Psychopharmacological treatment for cognitive impairment in survivors of traumatic brain injury: a critical review.

Traumatic brain injury (TBI) is a growing national health issue that commonly results in clinically significant cognitive impairments. This article reviews and evaluates the many proposed psychopharmacological treatments for TBI-related cognitive impairment. A literature review was utilized to focus on stimulant and nonstimulant dopamine enhancing agents, acetylcholinesterase inhibitors, antidepressant agents, mood stabilizers, antipsychotics, and benzodiazepines. The most consistent evidence supports the use of dopamine enhancing medications. However, other medications such as acetylcholinesterase inhibitors and antidepressant agents may help select subgroups. A need remains for well designed, sufficiently powered studies that incorporate functionally relevant neuropsychological outcome measures.