"You Really Never Forget It!" Psychiatry Trainee Supervision Needs and Supervisor Experiences Following the Suicide of a Patient.

OBJECTIVE: Suicide is the second leading cause of death in children, adolescents, and young adults ages 10-34 and the rates continue to rise in the USA. An estimated 30-60% of Psychiatry Residents experience patient suicide during their training. This study aimed to understand trainee and supervisor experiences after the suicide of a patient in order to better inform the supervision and response to such an event. METHOD: Twenty-seven participants were identified by criterion sampling and recruited from General Psychiatry residency, Consultation Liaison fellowship, and Child and Adolescent Psychiatry fellowship training programs in the New England region of the USA. Semi-structured interviews of trainees and supervisors were conducted and analyzed using inductive thematic analysis. RESULTS: The death of a patient by suicide was described as a notable event with a significant impact on the professional lives of the participants. The event was typically characterized as having an immediate emotional impact, led to changes in self-efficacy, and a sense of responsibility for the patient's death. Responses to suicide were influenced by modifiable factors such as (1) unpreparedness of individuals, program, and institution and (2) mediating/complicating factors, including the credibility of the supervisor, societal expectations, and specific patient characteristics. CONCLUSIONS: The death of a patient is a personal and emotional experience for the psychiatrist, for which they do not consistently feel well prepared. The institutional response may be misaligned, more analytical in character and prioritize assessment of risk. There is significant room to improve supervision and preparedness for the death of a patient by suicide.

Effective Research Mentorship for Residents: Meeting the Needs of Early Career Physicians.

OBJECTIVE: Challenges in pursuing research during residency may contribute to the shortage of clinician-scientists. Although the importance of mentorship in facilitating academic research careers has been described, little is understood about early career research mentorship for residents. The aim of this study was to better understand the mentorship process in the context of psychiatry residency. METHOD: Semi-structured interviews were conducted with experienced faculty mentors in a psychiatry department at a large academic medical center. Interviews were analyzed using inductive thematic analysis. Results from faculty interviews identified several key themes that were explored with an additional sample of resident mentees. RESULTS: Five themes emerged in our study: (1) being compatible: shared interests, methods, and working styles; (2) understanding level of development and research career goals in the context of residency training; (3) establishing a shared sense of expectations about time commitment, research skills, and autonomy; (4) residents' identity as a researcher; and (5) the diverse needs of a resident mentee. There was considerable congruence between mentor and mentee responses. CONCLUSIONS: There is an opportunity to improve research mentoring practice by providing guidance to both mentors and mentees that facilitates a more structured approach to the mentorship relationship.

Patient-provider communication over social media: perspectives of adolescents with psychiatric illness.

BACKGROUND: Social media is an increasingly dominant platform for communication, especially among adolescents. Statements from professional bodies and a growing body of empirical evidence support a role for social media in improving provider-patient interactions. In psychiatry, particular concerns exist about the suitability of this style of communication. Very limited data are available exploring how patients would like to incorporate social media into their communication with their psychiatric providers. METHODS: We conducted a qualitative study with 20 adolescents attending the Yale Psychiatric Hospital Intensive Outpatient Programme. Interviews were analysed using inductive thematic analysis. RESULTS: Participants highlighted how social media could allow for constant access to a mental health provider, provide a less anxiety-provoking mode of communication, and allow for them to be monitored in a more on-going fashion. However, participants also identified many potential risks associated with these applications, including the potential for anxiety if a provider was not able to respond immediately, and a sense that online interactions would be less rich overall. DISCUSSION: Our findings suggest that adolescents are open to the idea of communicating with mental health providers over social media and are able to describe a number of instances where this could be of value. The risks participants described, as well as concerns raised by existing literature, indicate the need for further work and protocol development in order for social media to be a feasible tool for communication between providers and adolescents with psychiatric illness.

Toward understanding the heterogeneity in obsessive-compulsive disorder: Evidence from narratives in adult patients.

BACKGROUND: Current attempts at understanding the heterogeneity in obsessive-compulsive disorder have relied on quantitative methods. The results of such work point toward a dimensional structure for obsessive-compulsive disorder. Existing qualitative work in obsessive-compulsive disorder has focused on understanding specific aspects of the obsessive-compulsive disorder experience in greater depth. However, qualitative methods are also of potential value in furthering our understanding of obsessive-compulsive disorder heterogeneity by allowing for open-ended exploration of the obsessive-compulsive disorder experience and correlating identified subtypes with patient narratives. OBJECTIVE: We explored variations in patients' experience prior to, during and immediately after performing their compulsions. METHOD: Semi-structured interviews were conducted with 20 adults with obsessive-compulsive disorder, followed by inductive thematic analysis. Participant responses were not analyzed within the context of an existing theoretical framework, and themes were labeled descriptively. RESULTS: The previous dichotomy of 'anxiety' vs 'incompleteness' emerged organically during narrative analysis. In addition, we found that some individuals with obsessive-compulsive disorder utilized their behaviors as a way to cope with stress and anxiety more generally. Other participants did not share this experience and denied finding any comfort in their obsessive-compulsive behaviors. The consequences of attentional difficulties were highlighted, with some participants describing how difficulty focusing on a task could influence the need for it to be repeated multiple times. CONCLUSIONS: The extent to which patients use obsessive-compulsive disorder as a coping mechanism is a relevant distinction with potential implications for treatment engagement. Patients may experience ambivalence about suppressing behaviors that they have come to rely upon for management of stress and anxiety, even if these behaviors represent symptoms of a psychiatric illness.

The Formation of Marijuana Risk Perception in a Population of Substance Abusing Patients.

Risk perception has been shown to be protective with regard to marijuana use. Notably, the risk perception of marijuana in individuals with substance abuse problems varies significantly from that of the general public. Understanding how risk perception is formed in substance users could explain these differences and help predict the consequences of policy changes. Using this framework, we explored risk perception and its formation in a sample of substance abusing veterans. Semi-structured interviews were conducted with veterans who were receiving treatment for substance abuse. Interviews were recorded digitally, transcribed verbatim, and analyzed using inductive thematic analysis. A prominent perspective among the 31 participants was that marijuana is significantly different from other drugs because it is safe, not addictive, not associated with physical withdrawal, and has less overt behavioral effects than other substances. Many of these participants drew upon their own innocuous experiences with the drug in developing this perspective, more so than information from any other source. A contrasting narrative emphasized marijuana's capacity to cause negative social consequences, act as a gateway to the use of other, more harmful substances, and cause paranoia or worsen psychosis. In conclusion, individual experience with marijuana featured more prominently in informing risk perception than any other source of information. Our results and previous literature suggest that the significant disconnect between the individual experiences of substance users and the current clinical and legal policy towards marijuana may weaken the legitimacy of public policy or the authority of the medical community.

Gender identity and autism spectrum disorders.

In this review, we briefly summarize much of the existing literature on gender-related concerns and autism spectrum disorders (ASD), drawing attention to critical shortcomings in our current understanding and potential clinical implications. Some authors have concluded that gender identity disorder (GID), or gender dysphoria (GD), is more common in individuals with ASD, providing a range of potential explanations. However, existing literature is quantitatively limited, and our capacity to draw conclusions is further complicated by conceptual challenges regarding how gender identity is best understood. Discourses that emphasize gender as a component of identity formation are gaining prominence and seem particularly salient when applied to ASD. Individuals with ASD should enjoy equal rights with regard to treatment for gender dysphoria. Clinicians may be able to assist individuals in understanding this aspect of their identity by broadening the social frame and facilitating an exploration of gender roles.

Autism Spectrum Disorders: In Theory and Practice.

Autism is a prevalent and strongly genetic brain-based disorder. Early focus in the field on the relevance of psychogenic factors led to the blaming of parents for the occurrence of the disorder, and as a result mainstream research on psychotherapeutic approaches has until recently been limited. Although psychoanalytic approaches continue to be considered of limited relevance for these individuals, dynamic theory is both informative and informed by conceptual approaches to the understanding of autism. Theory of mind in particular is a prominent model for understanding the core deficits of autism and bears strong resemblance to the concept of mentalization. Although cognitive-behavioral and social skills interventions may form the cornerstone of psychotherapy for individuals with autism, the formation of a treatment alliance remains crucial and may require a particular willingness for flexibility on the part of the therapist.

Plasma, oral fluid, and whole-blood distribution of antipsychotics and metabolites in clinical samples.

BACKGROUND: Oral fluid provides a noninvasive method of sample collection. The aim of this study was to obtain oral fluid, plasma, and whole blood from patients prescribed amisulpride, aripiprazole, clozapine, quetiapine, risperidone, or sulpiride and to measure plasma:whole blood and plasma:oral fluid analyte distribution. METHODS: Matched oral fluid, plasma and whole-blood samples were analyzed by liquid chromatography-tandem mass spectrometry. RESULTS: There were 101 sets of samples from 90 (56 male, 34 female) patients (nine prescribed 2 antipsychotics, and one 3). There were ≤ 5 samples for aripiprazole, amisulpride, and sulpiride. There was a good relationship between the plasma and hemolyzed whole-blood concentrations (R > 0.95), with plasma:whole-blood ratios varying between 0.7 (amisulpride) and 1.8 (aripiprazole). Amisulpride plasma and oral fluid concentrations were similar, whereas aripiprazole and dehydroaripiprazole oral fluid concentrations were approximately 8% of those in the plasma, reflecting the weak and strong plasma protein binding of these compounds, respectively. For the other analytes, plasma concentrations were 2-4 times higher than oral fluid concentrations. In general, there was a poor relationship (R = 0.3-0.7) between the plasma and oral fluid concentrations, possibly due to intrapatient saliva pH variation during sample collection. CONCLUSIONS: This work shows that hemolyzed whole-blood samples can be used for therapeutic drug monitoring purposes for the analytes of interest, provided that the plasma:whole-blood ratio is taken into account when interpreting results. For aripiprazole and dehydroaripiprazole, measurements in oral fluid will probably not be feasible. However, the relationship between plasma and oral fluid concentration for amisulpride, clozapine (and norclozapine), quetiapine (and possibly quetiapine metabolites), and risperidone/9-hydroxyrisperidone shows potential for oral fluid analysis.

Cutting to the chase: Participation factors, behavioral effects, and cultural perspectives of participants in an adult circumcision campaign.

Following the adoption of key national policy, several campaigns aimed at increasing the number of adult males receiving circumcisions have been implemented across South Africa. Evidence as to the likely effectiveness of such interventions comes predominantly from three large randomized-controlled trials. However, little has been written about how these campaigns are perceived by the participants. This is significant given the importance of the social issues that are implicit in determining both the ethical acceptability, and effectiveness of these campaigns. We report on a study aimed at identifying and exploring motivating factors for participation, behavioral effects, and cultural attitudes of participants towards a circumcision campaign undertaken in the Northern Cape Province. For this interpretive sociological research project, semi-structured interviews were conducted with 29 participants. These were recorded, transcribed, and qualitatively analyzed. The main reasons given for participation included that of reducing the risk of acquiring HIV and other sexually transmitted infections (STIs), as well as the enhancement of sexual experience. Participants insisted that they would continue to use condoms after the circumcision, although felt that other community members receiving circumcisions would not do so. Several advantages were described when receiving a circumcision at a public health facility, as opposed to the manner more traditional to the participant's culture. Whilst they did not report intentions for risk compensation, the reasons given for participation and their willingness to attribute this problem to other community members casts doubt on the veracity of their reported intentions. Furthermore, participants did not appear to have a complete understanding as to how circumcision is protective. Participants shared the belief that circumcisions as performed in the context of this campaign were safer than the traditional circumcision occurring in the area, which represents an important area for further research.

Pharmacologic and non-pharmacologic interventions for emotional lability: A meta-analysis.

Emotional Lability (EL) is a common symptom dimension in a variety of psychiatric disorders. However, as it is not typically a diagnosis in its own right, it lacks a consistently applied clinical definition and treatment approach. Therefore, in this review we performed a meta-analysis to determine the effect sizes for treatments of EL across diagnostic categories. We then conducted subgroup analyses to compare effect sizes for pharmacologic (MED) and behavioral (BEH) treatments, according to underlying diagnosis, and according to medication class. We found that pharmacologic and non-pharmacologic treatments are effective for EL, and that the effect sizes were similar - a finding with implications for clinical practice. Our findings also support future research which approaches EL as an important construct independent of underlying diagnosis.

Resilient Prescribing: An Approach to Psychotropic Use in Deployed Environments.

Resilient prescribing is an approach to the use of psychotropics that considers the significance of the treatment beyond the direct effects of the medication. Within this strengths-based approach, those who are prescribed medications must retain a sense of self-efficacy, understand the importance of their own actions in their recovery, have reasonable expectations of what a medication can and cannot do, and avoid the adoption of a disempowering illness identity. These constitute the principles of resilient prescribing. In this manuscript, we explore these principles with consideration for how they may be applied in deployed settings where the ability of service members to recover from behavioral health concerns is mission critical. These principles offer a roadmap to prescribing that builds upon the service members' own strengths and has the potential to amplify the positive impacts of mental health treatment.

Individual Therapy on Inpatient Units: Flexibility in the Face of Resistance.

The length of stay for inpatient adolescent admissions has decreased significantly over time.1 This has forced a reframing of the purpose of hospitalization as being focused on the tasks of maintaining safety, clarifying a diagnosis, optimizing medication, and arranging ongoing care. There are thus no standard approaches for the delivery of individual therapy that accommodate the complexity, heterogeneity, acuity, and time limitations of the inpatient setting. That being said, efforts continue to be made to provide some form of therapeutic engagement on inpatient units that goes beyond psychiatric assessment and basic nursing intervention. In this perspective, we describe a targeted approach toward individual therapy during acute hospitalization. This approach is applied successfully on a general inpatient adolescent unit in New England that maintains a low rate of restraints, seclusions, and readmission. Our unit treats verbal adolescents (younger youths and adolescents with significant cognitive or social learning limitations are accommodated in other settings within our community), but aspects of the approach have broader applicability. Guiding principles are drawn from a range of theoretical approaches, including collaborative problem solving,2 trauma-informed care,3 and strength-based care4 (Table 1). The program involves staff (activity therapists and nurses) being educated around key principles of a range of therapy modalities, which are then modeled by program leadership in multidisciplinary settings, such as walking rounds and group meetings. The approach is then incorporated into how the patient is engaged throughout the milieu. Staff education begins during initial onboarding to the unit, but then occurs in an iterative way as new patients with new therapeutic needs enter the milieu.

Drs. Turban and van Schalkwyk Reply.

In response to our Translations piece, 2 groups have written letters that include appropriate engagement with our arguments. However, they also dramatically misrepresent our original essay.1.

Antipsychotics for aggression in adults: A meta-analysis.

Aggressive behavior complicates the presentation of many psychiatric illnesses, and is associated with significant morbidity. Antipsychotic medications are used to treat this symptom dimension across multiple diagnoses. In this meta-analysis we sought to identify the effect size of antipsychotic medications for the treatment of reactive-impulsive aggression in adults, and identify differences across underlying diagnosis and specific agent. A search was conducted of four databases, MEDLINE, PsychINFO, Embase and the Cochrane Library to end date of August 10, 2016. The search terms included "aggression", "irritable mood", "anger", "hostility" and "antipsychotic agents" or "dopamine antagonists". 505 results were found, of which 47 were reviewed in detail and 21 ultimately included in the analysis. Antipsychotics were broadly effective for the treatment of aggression, but with effect sizes similar to those for non-pharmacologic interventions (standard mean difference=0.29, 95% confidence interval 0.22-0.36, z=8.5, p<0.001). There was no evidence for differences according to choice of agent (χ2=2.7, df=6, p=0.85), or conclusive evidence as to the importance of the underlying diagnosis (χ2=3.2, df=3, p=0.36). A small but significant dose effect was identified (ß=0.0002, 95% CI 0.0001-0.0004, p=0.038). Although antipsychotics appear to be effective for treatment of aggression, their small effect sizes in the context of their significant side-effects should be taken into account when making clinical decisions about their use.

Acute psychoactive effects of intravenous ketamine during treatment of mood disorders: Analysis of the Clinician Administered Dissociative State Scale.

INTRODUCTION: Ketamine has rapid-acting antidepressant effects. Frequently, ketamine administration also causes acute psychoactive effects - in trials, these effects are commonly measured using the Clinician Administered Dissociative State Scale (CADSS). However, the CADSS was not designed for this specific purpose, having been validated in other clinical contexts, and anecdotally does not appear to fully capture ketamine's acute psychoactive effects. METHODS: Data were obtained from 110 individuals with mood disorders (predominantly major depressive disorder) who underwent intravenous ketamine infusion. An exploratory factor analysis (EFA) was performed on the CADSS, along with assessment of internal consistency. Qualitative methods were used to conduct in-depth interviews with a subset of these participants to identify key features of the acute ketamine experience, including aspects that may not be captured by the CADSS. RESULTS: The mean total score of the CADSS was low at 7.7 (SD 9.2). Analysis of internal consistency showed a Cronbach's alpha of 0.74. Five CADSS items had low correlations with the total score. EFA lead to a one-factor solution containing 16 items. Five of the six highest loading items involved perceptual disturbances, either of time or sensation. Qualitative analyses of 10 patient narratives revealed two phenomena not captured on the CADSS: disinhibition and a sense of peace. LIMITATIONS: This study was by limited by the absence of other ratings of the participants' experience. CONCLUSION: Findings suggest that the CADSS partially captures the acute effects of ketamine administration. Further research may seek to validate a revised version of the CADSS that more accurately measures these effects.