The Path to Child and Adolescent Psychiatry

The United States has a critical shortage of child and adolescent psychiatrists such that 70% of counties in the United States do not have any child and adolescent psychiatrists.¹ Since 2014, the number of US and Canadian medical school applicants to psychiatry residencies has increased by 69%; however, the number of child and adolescent psychiatry fellowship applicants has increased by only 11%.² Up to two-thirds of psychiatry residents report considering a career in child and adolescent psychiatry; however, only one-fourth of residents ultimately apply for a child and adolescent psychiatry subspecialty training.^3,4 We surveyed child and adolescent psychiatry fellows across the country to understand the different pathways into child and adolescent psychiatry, with the hope of providing program directors' and faculty mentors' guidance on how to generate interest in child and adolescent psychiatry and to support residents in this pursuit.

Caregiving Factors as Predictors of Care Recipient Mortality

OBJECTIVE

Assess a conceptual model linking caregiving factors to care recipient mortality in a large representative sample of older adults with disability.

DESIGN

Descriptive longitudinal study with 5-year mortality follow-up among older adults with disability. Baseline in person and telephone interviews/assessments of older adults with disability and their family caregivers carried out in 2011.

SETTING

Representative samples of older US population and their family caregivers.

PARTICIPANTS

US representative samples of older adults with disability aged 65 and over (National Health and Aging Study) and their family caregivers (National Study of Caregiving; www.nhats.org; N = 1,262).

MEASUREMENT

Controlling for known risk factors for mortality in older adults, including age, gender, race, education, socioeconomic status, disability, and cognitive status, we assess the role of three caregiving factors (depression, anxiety, and burden) and three mediating factors (care recipient depression, anxiety, and unmet needs for care) as predictors of care recipient mortality.

RESULTS

Caregiver burden, care recipient depression, and care recipient unmet needs are independent predictors of care recipient mortality.

CONCLUSION

Caregiving factors may play an important role in the survival of their care recipients. This is a relatively unexplored research area that calls for fine-grained studies capturing caregiver-care recipient health-related interactions over time.

Intravenous haloperidol: A systematic review of side effects and recommendations for clinical use

INTRODUCTION

Though not approved by the United States Food and Drug Administration, intravenous haloperidol (IVH) is widely used off-label to manage agitation and psychosis in patients with delirium in the hospital setting. Over the years, concerns have emerged regarding side effects of IVH, particularly its potential to cause QT prolongation, torsades de pointes (TdP), extrapyramidal symptoms and catatonia.

METHODS

We conducted a systematic review of literature of published literature related to side effects of IVH in PubMed in accordance with PRISMA guidelines.

RESULTS

77 of 196 identified manuscripts met inclusion criteria, including 34 clinical trials and 34 case reports or series.

DISCUSSION

Extrapyramidal symptoms, catatonia and neuroleptic malignant syndrome appears to be relatively rare with IVH. In most prospective studies, IVH did not cause greater QT prolongation than placebo, and rates of TdP with IVH appear to be low. There is not clear evidence to suggest that IVH carries greater risk for QT prolongation or TdP than other antipsychotics.

CONCLUSIONS

Based on the available literature, we provide modified evidence-based monitoring recommendations for clinicians prescribing IVH in hospital settings. Specifically, we recommend electrocardiogram monitoring only when using doses >5 mg of IVH and telemetry only for high-risk patients receiving cumulative doses of at least 100 mg or with accurately corrected QTc >500 ms.

Optimizing Fit: Targeting a Residency Psychiatry Consultation-Liaison Rotation to Various Levels of Training

BACKGROUND

Determining the optimal timing and structure for a core residency rotation in consultation-liaison psychiatry (CLP) remains a key challenge for program directors and rotation leaders. Previous surveys have been conducted regarding these questions, and guidelines from national organizations have been issued, but practices remain varied among institutions.

METHODS

We conducted a narrative review of the literature related to the timing of CLP rotations and generated consensus recommendations based on our experience as program directors, rotation leaders, and residents.

RESULTS

Explicit goals of CLP training in residency include identifying and treating psychiatric manifestation of medical illness and communicating effectively with primary teams. Implicit goals of training may includeconflict management, limit setting, and "thinking dirty."

DISCUSSION

Although CLP rotations earlier in residency often create a better fit within the overarching curriculum and allow for generating early interest in the field, significant amounts of supervision are required, and consultees may look to attendings as the primary consultant. Conversely, while later rotations are sometimes challenging to structure with other outpatient responsibilities, they allow for greater autonomy and may map better onto the informal curriculum. A hybrid model, with training spread across multiple years, is another approach that may mitigate some of the disadvantages of confining consultation-liaison training to a single year. Compelling arguments can be made for placing the core CLP rotation in postgraduate year 2 or 3 or using a hybrid model. Regardless of placement, program directors and rotation leaders should be mindful of tailoring the rotation to the trainees' developmental stage.

Family Caregiving for Older Adults

Family members are the primary source of support for older adults with chronic illness and disability. Thousands of published empirical studies and dozens of reviews have documented the psychological and physical health effects of caregiving, identified caregivers at risk for adverse outcomes, and evaluated a wide range of intervention strategies to support caregivers. Caregiving as chronic stress exposure is the conceptual driver for much of this research. We review and synthesize the literature on the impact of caregiving and intervention strategies for supporting caregivers. The impact of caregiving is highly variable, driven largely by the intensity of care provided and the suffering of the care recipient. The intervention literature is littered with many failures and some successes. Successful interventions address both the pragmatics of care and the emotional toll of caregiving. We conclude with both research and policy recommendations that address a national agenda for caregiving.

Predictors of Patient Portal Use Among Community-Dwelling Older Adults

Older adults lag behind their younger counterparts in the use of patient portals, which may limit their ability to engage in health care. A better understanding of the factors associated with portal use among older adults is needed. We examined the proportion of 100 community-dwelling older adults who reported using a portal, the associations between sociobehavioral factors and portal use, and modeled predictors of portal use. Of the 52% who reported using a portal, 28% used the portal on their own, and 24% received assistance from others or had others access the portal on their behalf. After controlling for confounders, only marital status was significantly associated with any portal use. Marital status and patient activation were significantly associated with independent portal use. Further exploration is warranted to identify additional factors and the possible mechanisms underlying portal use by older adults. [Research in Gerontological Nursing, 14(1), 33-42.].

Adverse Consequences of Unmet Needs for Care in High-Need/High-Cost Older Adults

OBJECTIVES

We explore adverse consequences of unmet needs for care among high-need/high-cost (HNHC) older adults.

METHOD

Interviews with 4,024 community-dwelling older adults with ADL/IADL/mobility disabilities from the 2011 National Health and Aging Trends Study (NHATS). Reports of socio-demographics, disability compensatory strategies, and adverse consequences of unmet needs in the past month were obtained from older adults with multiple chronic conditions (MCC), probable dementia (DEM), and/or near end-of-life (EOL) and compared older adults not meeting these criteria.

RESULTS

Older adults with MCC (31.6%), DEM (39.6%), and EOL (48.7%) reported significantly more adverse consequences than low-need older adults (21.4%). Persons with MCC and DEM (53.4%), MCC, and EOL (53.2%), and all three (MCC, DEM, EOL, 65.6%) reported the highest levels of adverse consequences. HNHC participants reported more environmental modifications, assistive device, and larger helper networks. HNHC status independently predicted greater adverse consequences after controlling for disability compensatory strategies in multivariate models.

DISCUSSION

Adverse consequences of unmet needs for care are prevalent among HNHC older adults, especially those with multiple indicators, despite more disability-related compensatory efforts and larger helper networks. Helping caregivers provide better informal care has potential to contain healthcare costs by reducing hospitalization and unplanned readmissions.

Post-stroke depression: A 2020 updated review

BACKGROUND

Post-stroke depression (PSD) is common and associated with higher mortality, poorer recovery, more pronounced cognitive deficits, and lower quality of life than is stroke without depression. This manuscript will conduct an updated, comprehensive and clinically-useful review of the risk factors, pathophysiology, assessment, prevention, and treatment of PSD.

METHODS

This narrative review summarizes articles obtained on PubMed, Medline, EMBase, Google Scholar and the Cochrane Database. This review prioritized articles with a more robust level of evidence, such as original articles with longitudinal data and/or larger samples, randomized controlled trials, systematic reviews, and metaanalyses.

RESULTS

One hundred twenty-four articles were reviewed, of which 44 (35%) were published before 2016 and 80 (65%) that were published since 2016.

DISCUSSION

Rates of PSD range from 18 to 33%, yet it is vastly underdiagnosed and undertreated. Risk factors for PSD include female sex, history of psychiatric illness, large or multiple strokes, injuries in frontal/anterior areas or in the basal ganglia, stroke occurrence within the past year, poor social support, and pronounced disability. The pathophysiology of PSD is multifactorial and likely involves decreased levels of monoamines, abnormal neurotrophic response, increased inflammation with dysregulation of hypothalamic-pituitary-adrenal axis, and glutamate-mediated excitotoxicity. The evidence for preventive interventions for PSD is somewhat inconsistent and modest. The best treatment for PSD consists of the combination of pharmacological, psychosocial and stroke-focused interventions.

CONCLUSION

PSD is a common, treatable condition that is associated with several negative outcomes. Early detection and proper management are critical to obtain better outcomes in individuals with PSD.

Psychiatry Resident Attitudes Toward Practice Habit Data

OBJECTIVE

This descriptive study queries the attitudes of psychiatry residents regarding provision of practice habit data to trainees by residency programs, as required by the Accreditation Council for Graduate Medical Education (ACGME). Identifying trainee perspectives may assist program directors in tailoring practice habit data reporting to better engage residents and to increase resident-reported adherence to the ACGME requirement.

METHODS

Residents at a large, hospital-based adult psychiatry training program completed an anonymous survey of attitudes regarding practice habit data, including perceptions of the residency program's current reporting, preferences toward mechanisms of delivering this data, and perceived relative utility of five hypothetical domains of practice habit data.

RESULTS

Of 61 eligible residents, 52 (85%) completed surveys. Only 29 (56%) recalled receiving prior-year individual practice habit data, and only 10 (19%) recalled receiving team-based data. Seventy-five percent desired more practice habit data. Out of five hypothetical thematic domains for practice habit reporting, residents preferred patient-oriented domains as opposed to process-oriented domains. Resident concerns about dissemination of these data included confidentiality, effect on evaluations, and difficulty translating data to changes in clinical practice.

CONCLUSIONS

Residents generally desire increased dissemination of practice habit data that focuses on patient-oriented measures such as adherence to disease-specific guidelines and is both individual and team-based. Residency programs may benefit their trainees and improve resident-reported adherence to the ACGME requirement both by taking resident preferences into account and by addressing concerns about confidentiality when providing practice habit data.

The Importance of Investigating Abuser Characteristics in Elder Emotional/Psychological Abuse: Results from Adult Protective Services Data

OBJECTIVES

Elder emotional/psychological abuse is the infliction of mental anguish on older adults through verbal or non-verbal acts. Using indicators based on existing literature, theoretically important abuser characteristics and victim vulnerabilities were collected using the Elder Abuse Decision Support System (EADSS) to test a theory of emotional/psychological abuse.

METHOD

Eight-hundred-and-ten alleged emotional/psychological abuse cases were investigated by caseworkers in six Illinois adult protective services (APS) agencies; 466 individuals endorsed at least one item on the Older Adult Psychological Abuse Measure (OAPAM).

RESULTS

Bivariate ordinary linear regression results established that all abuser characteristics were predictive of emotional/psychological abuse scores. In the hierarchical regression model where abuser characteristics were entered after victim vulnerabilities, abuser characteristics predicted emotional/psychological abuse above and beyond victim vulnerabilities (ΔR2 = 0.349, p < .001). Abuser risk and abuser's negative attitudes towards victims remained as significant predictors in the final model. Post hoc analysis identified significant items of abuser risk and negative attitudes, including: an emotionally draining relationship between abuser and victim, abuser's poor temper control, and abuser's angry feelings towards victims.

DISCUSSION

Abuser weaknesses and strengths as highlighted in the theoretical framework should be further investigated for future prevention and intervention in cases of emotional/psychological abuse.

Neurocovid: Pharmacological Recommendations for Delirium Associated With COVID-19

Background

The pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has emerged as one of the biggest health threats of our generation. A significant portion of patients are presenting with delirium and neuropsychiatric sequelae of the disease. Unique examination findings and responses to treatment have been identified.

Objective

In this article, we seek to provide pharmacologic and treatment recommendations specific to delirium in patients with COVID-19.

Methods

We performed a literature search reviewing the neuropsychiatric complications and treatments in prior coronavirus epidemics including Middle Eastern respiratory syndrome and severe acute respiratory syndrome coronaviruses, as well as the emerging literature regarding COVID-19. We also convened a work group of consultation-liaison psychiatrists actively managing patients with COVID-19 in our hospital. Finally, we synthesized these findings to provide preliminary pharmacologic recommendations for treating delirium in these patients.

Results

Delirium is frequently found in patients who test positive for COVID-19, even in the absence of respiratory symptoms. There appears to be a higher rate of agitation, myoclonus, abulia, and alogia. No data are currently available on the treatment of delirium in patients with COVID-19. Extrapolating from general delirium treatment, Middle Eastern respiratory syndrome/severe acute respiratory syndrome case reports, and our experience, preliminary recommendations for pharmacologic management have been assembled.

Conclusions

COVID-19 is associated with neuropsychiatric symptoms. Low-potency neuroleptics and alpha-2 adrenergic agents may be especially useful in this setting. Further research into the pathophysiology of COVID-19 will be key in developing more targeted treatment guidelines.

Delirium in COVID-19: A case series and exploration of potential mechanisms for central nervous system involvement

INTRODUCTION

Neuropsychiatric manifestations of the coronavirus disease 2019 (COVID-19) have been described, including anosmia, ageusia, headache, paresthesia, encephalitis and encephalopathy. Little is known about the mechanisms by which the virus causes central nervous system (CNS) symptoms, and therefore little guidance is available regarding potential workup or management options.

CASES

We present a series of four consecutive cases, seen by our psychiatry consultation service over a one-week period, each of which manifested delirium as a result of infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2).

DISCUSSION

The four cases highlighted here all occurred in older patients with premorbid evidence of cognitive decline. Unique features seen in multiple cases included rigidity, alogia, abulia, and elevated inflammatory markers. In all four cases, a change in mental status was the presenting symptom, and three of the four cases lacked significant respiratory symptoms. In addition to discussing unique features of the cases, we discuss possible pathophysiologic explanations for COVID-19 delirium.

CONCLUSIONS

Delirium should be recognized as a potential feature of infection with SARS-CoV-2 and may be the only presenting symptom. Based on the high rates of delirium demonstrated in prior studies, hospitals should consider adding mental status changes to the list of testing criteria. Further research is needed to determine if delirium in COVID-19 represents a primary encephalopathy heralding invasion of the CNS by the virus, or a secondary encephalopathy related to systemic inflammatory response or other factors.

FINANCIAL EXPLOITATION OF OLDER ADULTS: PRELIMINARY RESULTS FROM A PROSPECTIVE LONGITUDINAL STUDY

This paper presents study design and preliminary results from a new study funded by the National Institute on Aging that is examining financial exploitation (FE) among 720 White, African-American and Hispanic adults age 60+ (240 per group; 120 age 60-79; 120 age 80+). A conceptual model linking socio-demographics, physical health, social support / integration, cognitive function, financial skills / supports, and psychosocial factors to FE is being evaluated. Three assessments (baseline, 12; 24 mos.) include: a detailed cognitive battery, web-based banking simulation tasks, scam scenarios, and a standardized battery of self-report measures assessing socio-demographic and psychosocial variables. Preliminary baseline results from ~200 participants show support for the proposed model. Exposure to sales, remote purchasing behavior, and telemarketer receptivity (scam exposure); and scam vulnerability as measured by credibility ratings of “legitimate” and “fake” scam scenarios are positively associated with reports of both stranger-initiated and trusted other FE. Older adults with smaller social networks and less social support were more likely to report both exposure and vulnerability to scams. Higher general cognitive abilities, financial skills, and numeracy; and better performance on online banking tasks correlate with less scam exposure and vulnerability. Preliminary analyses of psychosocial factors also show that more depressed, impulsive, and trusting older adults report more exposure and scam vulnerability. The paper will present updated analyses of ~500 baseline participants. Understanding multiple pathways to FE is important to advance theory and for the development of interventions to minimize risk.

DESIGNING TECHNOLOGY TO SUPPORT HEALTHCARE FOR AGING ADULTS

Healthcare costs are rising in industrialized countries, partly as a function of managing costly chronic care conditions associated with aging populations. Of roughly 3 trillion USD expended in the U.S., almost 90% is spent on those with chronic conditions. Technology is touted as one tool to manage healthcare efficiently. However, human factors research has shown that technological systems that do not take human capabilities into account will fail to be adopted, or if adopted, will be abandoned by users. The Center for Research and Education on Aging and Technology Enhancement (CREATE) will describe research findings for four different facets of healthcare technology. Sara Czaja will provide an overview, describing technology for healthcare support. Caregiver needs are projected to rise rapidly, in part due to aging of the baby boom cohorts. We need new solutions for future generations of older adults as there will be insufficient numbers of caregivers to care for the increased number of older adults given changes in social structures. Wendy Rogers will discuss research on the design and use of televideo and robots to assist with healthcare. Neil Charness will discuss home monitoring technology, particularly practical issues around design, deployment, and maintenance, drawing on studies of heart failure patients and older adult controls. Walter Boot will discuss how gamification of healthcare interventions can help to address the adherence problem for behavior change. Scott Beach, Associate Director & Director of Survey Research Program, University Center for Social and Urban Research, University of Pittsburgh, will serve as discussant.

Do Family Caregivers Offset Healthcare Costs for Older Adults? A Mapping Review on the Costs of Care for Older Adults With Versus Without Caregivers

BACKGROUND AND OBJECTIVES

Older adults face significant long-term care and health care costs. But some of these costs can potentially be offset through family caregivers who may serve as substitutes for formal care or directly improve the care recipient's health and reduce health care utilization and expenditures. This article reviews the current literature to determine whether it is possible through existing work to compare the costs of care for individuals with versus without family caregivers and, if not, where the data, measurement, and other methodological challenges lie.

RESEARCH DESIGN AND METHODS

A mapping review of published works containing information on health care utilization and expenditures and caregiving was conducted. A narrative approach was used to review and identify methodological challenges in the literature.

RESULTS

Our review identified 47 articles that met our criteria and had information on caregiving and health care costs or utilization. Although findings were mixed, for the most part, having a family caregiver was associated with reduced health care utilization and a decreased risk of institutionalization however, the precise difference in health care expenditures for individuals with caregivers compared to those without was rarely examined, and findings were inconsistent across articles reviewed.

DISCUSSION AND IMPLICATIONS

The number of family caregivers providing care to loved ones is expected to grow with the aging of the Baby Boomers. Various programs and policies have been proposed to support these caregivers, but they could be costly. These costs can potentially be offset if family caregivers reduce health care spending. More research is needed, however, to quantify the savings stemming from family caregiving.

Caregiving and Place: Combining Geographic Information System (GIS) and Survey Methods to Examine Neighborhood Context and Caregiver Outcomes

Background

Little is known about the impact of neighborhood context on family caregivers, or how environmental factors combine with individual-level caregiver risk factors to affect caregiver outcomes.

Objectives

To combine Geographic Information System (GIS) and survey methods to examine the effects of caregiver residence in disadvantaged/underserved neighborhoods on caregiver outcomes.

Research Design and Methods

Telephone surveys with 758 caregivers from the Pittsburgh Regional Caregiver Survey geocoded for classification into Environmental Justice Areas (EJAs) and Medically Underserved Areas (MUAs). We examine the impact of EJA/MUA caregiver residence on care recipient unmet needs for care, caregiver depression and burden, and positive aspects of caregiving, adjusting for sociodemographics, caregiving context, care recipient disability level, caregiving intensity, and additional risk factors.

Results

There was spatial clustering of caregiver depression and burden outside of the disadvantaged/underserved areas, while positive aspects of caregiving were clustered within EJAs/MUAs. Approximately 36% of caregivers lived in EJAs/MUAs, and they differed, sociodemographically, on caregiver risk factors and caregiver outcomes. Multivariable models showed that caregivers residing in EJAs/MUAs were less likely to be depressed and reported more positive aspects of caregiving after adjusting for known individual-level risk factors. Residence in disadvantaged/underserved areas also modified the effects of several risk factors on caregiver outcomes.

Discussion and Implications

Caregiver outcomes show interesting spatial patterns. Unexpectedly, caregivers living in these potentially challenging environments were less depressed and reported more gains from caregiving after adjusting for known risk factors. Results suggest that socioeconomic disadvantage does not necessarily translate into poor caregiver outcomes. Understanding the mechanism for these effects is important to designing effective caregiver interventions. The paper also demonstrates the value of using GIS methods to study caregiving.

Research Use of Ecological Momentary Assessment for Adverse Event Monitoring Following Amyloid-β Results Disclosure

As calls for transparency in human subjects research grow, investigators conducting Alzheimer’s disease (AD) biomarker research are increasingly required to consider their ethical obligations regarding the return of AD biomarker test results to research participants. When disclosing these test results to potentially vulnerable participants, investigators may face unique challenges to identify adverse events, particularly psychological events. The purpose of this paper is to describe our research team’s experience with developing and implementing a process for enhanced adverse event monitoring following the return of amyloid-β (Aβ) imaging results to research participants with mild cognitive impairment (MCI). Ethical and logistical considerations are presented along with preliminary findings from an ongoing randomized controlled trial of Aβ imaging results disclosure in MCI. Following receipt of amyloid imaging results, participants underwent 14 days of adverse event monitoring using ecological momentary assessment (EMA), a strategy to capture health, behaviors, and mood as they occur in participants’ natural settings in real time. EMA telephone calls were placed at random during waking hours to screen for mood changes. Investigators were alerted for positive depression, anxiety, suicidal ideation screenings, or for two days of failed call attempts. Preliminary feasibility of twenty-four participants with MCI who participated in EMA mood assessments was successfully completed 83% (SD = 0.4) of the time over 14 days with no alerts for anxiety or depression screening items. EMA, when used with standard adverse event monitoring, is a promising and novel approach to maximize early detection of negative psychological reactions following AD biomarker results disclosed in research settings.

After Hours: A Survey of Moonlighting Practices in Psychiatry Residents

OBJECTIVE

The authors surveyed psychiatry residents to determine who participates in moonlighting and to understand their views and opinions on the necessity, importance, and educational value of moonlighting.

METHODS

An electronic survey was distributed to psychiatry residents at 16 programs nationally. Descriptive characteristics were calculated. Logistic and linear regressions were performed to determine differences between those who moonlight and those who do not and to assess differences in measures of financial distress, quality of life, and work-life balance.

RESULTS

A total of 173/624 (27.6%) residents participated. Within the subset allowed to moonlight, 50% (47/94) reported moonlighting during prior academic year, for an average of 17.4 ± 8.6 hoursh per month. Within those eligible to moonlight, there were no differences in perceived financial distress, quality of life, work-life balance, and confidence between residents who moonlighted and those who did not. Among moonlighters, 10.6% moonlighted overnight before working the next day, and only 68.1% included moonlighting when recording duty hours. 45% reported no supervision available while moonlighting.

CONCLUSIONS

In the study sample, 50% of psychiatry residents eligible to moonlight opted to do so. Though most programs have policies in place regarding moonlighting, programs may benefit from ensuring that residents are reporting moonlighting in duty hours and that supervision is available to those moonlighting.