Psychiatry Resident Quality of Life.

OBJECTIVE: The objective of this study was to evaluate psychiatry resident physician quality of life. METHODS: A voluntary, anonymous, 10-min survey was e-mailed to residents from all 14 Accreditation Council for Graduate Medical Education (ACGME)-accredited programs in Pennsylvania, New Jersey, and Delaware. Included in the survey was the Multi-Cultural Quality of Life Inventory (MQLI). RESULTS: Response rate was 112 (34.1%). Internal consistency of the MQLI was high (Cronbach's alpha 0.92), and follow-up exploratory factor analysis extracted only one underlying factor (60.1% variance among all 10 items). Average total MQLI score was 80.6. No significant difference in MQLI total was found for therapy status, sex, or race. Post-graduate year (PGY) 4 residents scored higher on total MQLI score (86.7) (F = 2.80, p = 0.04) and ranked occupational functioning and community and services support subscales significantly higher (occupation F = 2.73, p = 0.048, community F = 3.11, p = 0.030). Total MQLI score for residents over the age of 40 (n = 3) was significantly lower (F = 3.45, p = 0.019). CONCLUSION: Despite the stresses of residency training, residents from a variety of programs in one geographic area report an encouraging quality of life on the MQLI. Psychiatry resident quality of life is similar to that reported in other populations of mental health professionals.

Psychotherapy Training: Residents' Perceptions and Experiences.

OBJECTIVE: This survey examined actual training hours in psychotherapy modalities as reported by residents, residents' perceptions of training needs, and residents' perceptions of the importance of different aspects of psychotherapy training. METHOD: A brief, voluntary, anonymous, Internet-based survey was developed. All 14 program directors for Accreditation Council for Graduate Medical Education accredited programs in Pennsylvania, New Jersey, and Delaware provided email addresses for current categorical residents. The survey inquired about hours of time spent in various aspects of training, value assigned to aspects of training, residents' involvement in their own psychotherapy, and overall resident wellness. The survey was e-mailed to 328 residents. RESULTS: Of the 328 residents contacted, 133 (40.5%) responded. Median reported number of PGY 3 and 4 performed versus perceived ideal hours of supportive therapy, cognitive behavioral therapy (CBT), and psychodynamic therapy did not differ. Answers for clinical time utilizing these modalities ranged from "none or less than 1 h" per month to 20+ h per month. PGY 3 and 4 residents reported a median of "none or less than 1 h" per month performed of interpersonal, dialectical behavior therapy, couples/family/group, and child therapies but preferred more time using these therapies. Residents in all years of training preferred more hours of didactic instruction for all psychotherapies and for medication management. Residents ranked teaching modalities in the following order of importance: supervision, hours of psychotherapy performed, personal psychotherapy, readings, and didactic instruction. Residents engaged in their own psychotherapy were significantly more likely to rank the experiential aspects of psychotherapy training (personal psychotherapy, supervision, and hours performed) higher than residents not in psychotherapy. CONCLUSION: Current psychotherapy training for psychiatry residents is highly variable, but overall, residents want more psychotherapy education than they are receiving. Further research and discussion about how much psychotherapy training is feasible in an evolving field is required.

Use and characterization of personal psychotherapy by psychiatry residents.

OBJECTIVE: The authors evaluated psychiatry resident participation in and description of personal psychotherapy, reasons for being in psychotherapy, and barriers to personal psychotherapy. METHODS: All 14 program directors for programs accredited by the Accreditation Council for Graduate Medical Education in Pennsylvania, New Jersey, and Delaware provided e-mail addresses for current categorical residents. The authors e-mailed a voluntary, anonymous, 10-min survey to residents through www.SurveyMonkey.com . The survey inquired about time spent in various aspects of training, value assigned to aspects of training, residents' involvement in their own psychotherapy, reasons for being in or not being in therapy, and overall resident wellness. RESULTS: Of the 328 residents e-mailed, 133 (40.5 %) replied to the survey, of which 34 (26.5 %) were in personal psychotherapy. Most residents described their psychotherapy as psychodynamic, once weekly, and located in a private practice not affiliated with the resident's academic center. Approximately half (49 %) were in treatment with a social worker (MSW, LCSW) or psychologist (PhD or PsyD). "Self-awareness and understanding" was the most commonly reported primary and contributing reason for being in psychotherapy. Close to half of the respondents (44.5 %) listed personal stress, substance dependence, mood, anxiety, or other psychiatric symptoms as the primary reason for seeking personal psychotherapy. The most common reasons for not entering psychotherapy were time and finances. Residents who were in personal psychotherapy valued personal psychotherapy as more important to training than residents who were not in personal psychotherapy. Half of all respondents reported that their program recommends psychotherapy. CONCLUSION: Far fewer residents responding to the survey reported being in psychotherapy than residents from some previous surveys. A continuing discussion of whether and how to accommodate personal psychotherapy in the training and education of psychiatry residents by psychiatry educators is warranted.

Emergency management of agitation in pregnancy.

OBJECTIVE: This study aimed to better understand how agitated pregnant women are pharmacologically managed in a psychiatric emergency service (PES). METHOD: A retrospective chart review was conducted on 80 women admitted to a PES with HCG-positive urine, from January 1, 2004, to June 30, 2005. Of these, 31 patients required medication for agitation. We describe the demographics (age, ethnicity, housing status, insurance status), chief complaint, medical status, drug use and medical management in the PES, as well as pregnancy awareness, prenatal care and trimester. Patient data were analyzed using simple frequency calculations and cross tabulations with SPSS. RESULTS: Thirty-one (39%) patients received 34 doses of psychotropic medication. Haloperidol, alone or in combination with a benzodiazepine, was the most frequently administered psychotropic medication, while risperidone was the second most commonly administered medication. Two patients required brief restraint for assaultive behavior that was unresponsive to any other intervention. CONCLUSION: There are algorithms that provide guidance to clinicians regarding the pharmacological management of aggression. However, there are no efficacy or safety studies that recommend strategies for the management of the agitated pregnant patient.

Medication adherence: a review of the literature and implications for clinical practice.

Adherence is defined as the extent to which a patient's behavior coincides with medical or prescribed health advice. Adherence is considered non-judgmental and is preferred over the term "compliance," which carries negative connotations and suggests blame for the patient. A major challenge in the field of psychiatry has been to understand why patients may or may not adhere to medication and other treatment recommendations. A comprehensive review of the literature on medication adherence among patients with psychiatric illnesses was conducted with the following objectives: (1) to better understand the impact of medication nonadherence, (2) to identify risk factors for medication nonadherence, and (3) to study interventions designed to improve patient adherence. The authors initially searched the Ovid Medline electronic database using the key words "medication adherence" and "compliance" to identify all articles written in the English language published through early 2008. This produced over 2000 references. The search was then narrowed to publications specific to psychotropic medication. The ultimate goal of the review was to increase awareness of this critical issue and to discuss strategies that the psychiatric clinician can implement to address patient adherence to prescribed medications. The authors chose to include articles that were deemed to be clinically useful to the practicing clinician.Studies that have specifically investigated adherence to psychiatric medications vary in the definitions of adherence and methodology that were used, making interpretation of results across studies difficult. Psychoeducational interventions have long been the mainstay of treatment for adherence problems. However, there is growing evidence that other approaches such as cognitive-behavioral strategies and motivational interviewing may be effective. Based on a comprehensive literature review, the authors recommend the following strategies for addressing adherence problems: focus on strengthening the therapeutic alliance; devote time in treatment specifically to address medication adherence; assess patients' motivation to take prescribed medications; and identify and address potential barriers to treatment adherence.

Caffeine-Associated Cardiac Dysrhythmia During ECT: Report of Three Cases.

Caffeine is increasingly being used by ECT practitioners to augment seizure duration in selected patients. We note one report of adverse cardiovascular effects with this procedure. We report three cases of severe cardiac dysrhythmia, all appearing in the present of caffeine. The three patients were elderly, with a prior history of cardiac illness. The authors recommend the use of nonpharmacologic alternatives for the treatment of brief seizures, and careful review of each patient's cardiac history before utilizing caffeine. They further urge continued monitoring in those patients for whom caffeine is introduced. Further prospective studies are needed to assess carefully the risk of caffeine pretreatment in patients with cardiac disease.

Problems in Maintenance ECT in Bipolar Disorder: Replacement by Lithium and Anticonvulsants.

The authors describe three elderly patients whose electroconvulsive therapy (ECT) was characterized by protracted and unsatisfactory courses and frequent relapse. Sustained improvement resulted from the discontinuation of maintenance ECT and continuation of pharmacotherapy with combinations of lithium and carbamazepine or valproic acid. The patients are compared to a more typical patient with bipolar disorder who was successfully treated with long-term maintenance ECT. Difficulties in identifying and treating patients with atypical bipolar disorder are discussed.

Maintenance ECT in Coexisting Affective and Neurologic Disorders.

To the numerous reports of the safety and efficacy of electroconvulsive therapy (ECT) in acute depressive episodes in patients with coexisting neurologic illness, the authors report their experience with two patients treated with maintenance ECT for more than 2 years. The authors find maintenance ECT useful in ameliorating the depressive illness without worsening the neurologic illness.