Employment in Office-Based and Intensive Behavioral Health Settings in the US, 2016-2021

This study uses employment census data to show trends in behavioral health employment during and after the COVID-19 pandemic.

Representation of women at American Psychiatric Association annual meetings over 10 years (between 2009 and 2019)

OBJECTIVE

Sex disparity is a major societal issue. The aim of this paper was to describe changes in the representation of women among speakers of the American Psychiatric Association (APA) annual meeting over 10 years, between 2009 and 2019 and to compare them to changes in the proportion of women among American psychiatrists.

METHODS

Data were collected from the programs of the APA annual meetings of 2009 and 2019, and from the Association of American Medical Colleges. Descriptive and comparative statistical analyses were performed.

RESULTS

There were 1,138 distinct speakers at the 2009 conference and 1,784 at the 2019 conference. The number of distinct female speakers increased from 413 (36.3%) to 813 (45.6%). The proportion of female speakers at the meetings was almost equivalent to the proportion of women in the American psychiatrists' workforce. The number of female chairs increased from 158 (39.6%) to 322 (46.4%). There were 38 female speakers in child and adolescent psychiatry in 2009 (51.4% of 74 speakers) and 74 in 2019 (51.0% of 155 speakers).

CONCLUSIONS

The representation of women at the APA annual meetings increased between 2009 and 2019. At the same time, the growth in the percentage of women in the American psychiatrists' workforce was slower. The APA appears to promote female representation during its annual meetings.

A new bottom-up method for the standard analysis and comparison of workforce capacity in mental healthcare planning: Demonstration study in the Australian Capital Territory

The aims of this study are to evaluate and describe mental health workforce and capacity, and to describe the relationship between workforce capacity and patterns of care in local areas. We conducted a comparative demonstration study of the applicability of an internationally validated standardised service classification instrument—the Description and Evaluation of Services and Directories—DESDE-LTC) using the emerging mental health ecosystems research (MHESR) approach. Using DESDE-LTC as the framework, and drawing from international occupation classifications, the workforce was classified according to characteristics including the type of care provided and professional background. Our reference area was the Australian Capital Territory, which we compared with two other urban districts in Australia (Sydney and South East Sydney) and three benchmark international health districts (Helsinki-Uusima (Finland), Verona (Italy) and Gipuzkoa (Spain)). We also compared our data with national level data where available. The Australian and Finnish regions had a larger and more highly skilled workforce than the southern European regions. The pattern of workforce availability and profile varied, even within the same country, at the local level. We found significant differences between regional rates of identified rates of psychiatrists and psychologists, and national averages. Using a standardised classification instrument at the local level, and our occupational groupings, we were able to assess the available workforce and provide information relevant to planners about the actual capacity of the system. Data obtained at local level is critical to providing planners with reliable data to inform their decision making.

Going Virtual During a Pandemic: An Academic Psychiatry Department's Experience with Telepsychiatry

Background

The novel coronavirus pandemic (COVID-19) led healthcare providers, including mental health providers, across the U.S. to swiftly shift to telemedicine.

Objectives

This shift gave our Department of Psychiatry a chance to better understand key challenges and opportunities vis-à-vis virtual mental healthcare. We aimed to obtain provider feedback on the use of telepsychiatry and to learn from the provider perspective about patient experiences with video visits. This information will be used to inform the telemedicine strategy at a systems level within our psychiatry department, our academic health system, as well as the field of telemedicine as a whole.

Design and Sample

A 22-item online questionnaire comprising 16 quantitative and six qualitative items was distributed to providers currently using video visits to provide care.

Results

A total of 89 mental health providers completed the questionnaire. Outcomes demonstrated that while providers perceive challenges associated with virtual care (e.g., fatigue, technology-related issues, and age-related concerns), they also recognize a number of benefits to themselves and their patients (e.g., convenience and increased access). Overall, provider satisfaction, comfort, and willingness to use telepsychiatry was high.

Conclusions

The vast majority of providers adapted quickly to the use of virtual platforms; many endorse advantages that suggest virtual care will continue to be a modality they provide in the future, post-COVID-19. It will be important to continue to evaluate aspects of virtual care that may limit clinical assessments and to optimize use to improve access, convenience, and cost-efficiency of mental healthcare delivery.

Accuracy of initial psychiatric diagnoses given by nonpsychiatric physicians: A retrospective chart review

Despite the increased morbidity and mortality associated with psychiatric illnesses, there remains a substantial level of inaccuracy of the initial psychiatric diagnoses given by nonpsychiatric physicians. This study examines the accuracy of initial psychiatric diagnoses by non-psychiatric physicians at the McGill University Health Center (MUHC).We conducted a retrospective chart review for all consultations requested from the consultation-liaison psychiatry service at MUHC. We included all the consultations from January 1, 2018, to December 30, 2018, and excluded patient data with established psychiatric diagnoses. In all requested consults, each diagnosis of a referring physician was compared with the final diagnosis given by the C-L psychiatry team. Conformity between the 2 was validated as accurate.Of the 980 referred inpatients, 875 were enrolled. Patients ranged in age and those older than 70 years constituted the largest group: 54.4% were male. For 467 patients (55.20%), the initial diagnostic impression given by the referring physicians agreed with the final diagnosis made by the C-L psychiatry team, while in 379 patients (44.80%), the initial diagnostic impression was not consistent with the final diagnosis made by the C-L team.Diagnostic impressions of neurocognitive and substance use disorders were highly accurate, but this was not the case when the referring physicians suspected depression or bipolar, personality, or psychotic disorders. This study shows that around half of the referrals were accurately diagnosed, which evinces that nonpsychiatric physicians' knowledge regarding psychiatric conditions is not optimal and that might negatively impact screening and treating these conditions.

Artificial Intelligence in mental health and the biases of language based models

BACKGROUND

The rapid integration of Artificial Intelligence (AI) into the healthcare field has occurred with little communication between computer scientists and doctors. The impact of AI on health outcomes and inequalities calls for health professionals and data scientists to make a collaborative effort to ensure historic health disparities are not encoded into the future. We present a study that evaluates bias in existing Natural Language Processing (NLP) models used in psychiatry and discuss how these biases may widen health inequalities. Our approach systematically evaluates each stage of model development to explore how biases arise from a clinical, data science and linguistic perspective.

DESIGN/METHODS

A literature review of the uses of NLP in mental health was carried out across multiple disciplinary databases with defined Mesh terms and keywords. Our primary analysis evaluated biases within 'GloVe' and 'Word2Vec' word embeddings. Euclidean distances were measured to assess relationships between psychiatric terms and demographic labels, and vector similarity functions were used to solve analogy questions relating to mental health.

RESULTS

Our primary analysis of mental health terminology in GloVe and Word2Vec embeddings demonstrated significant biases with respect to religion, race, gender, nationality, sexuality and age. Our literature review returned 52 papers, of which none addressed all the areas of possible bias that we identify in model development. In addition, only one article existed on more than one research database, demonstrating the isolation of research within disciplinary silos and inhibiting cross-disciplinary collaboration or communication.

CONCLUSION

Our findings are relevant to professionals who wish to minimize the health inequalities that may arise as a result of AI and data-driven algorithms. We offer primary research identifying biases within these technologies and provide recommendations for avoiding these harms in the future.

Similarities and Differences Between Rural and Urban Telemedicine Utilization

Telemedicine has traditionally been used in rural areas, but the recent development of mHealth solutions has led to a growth in urban telemedicine services. The aim of this study was to determine whether urban and rural patients in a large academic medical center use telemedicine to access different healthcare specialties at different rates. This retrospective cohort study examined all telemedicine visits dated 2008-2017 at a large academic medical center. Visits were classified by clinical specialty. Teledermatology, child telepsychiatry, and adult telepsychiatry made up 97 percent of telemedicine visits. Rural patients were more likely to have multiple telehealth visits. A significant difference was observed between rural and urban use of telemedicine, both in terms of specialties and demographics. This suggests that health systems should consider adjusting resources and training to meet the different needs of these two populations. In particular, telemedicine may offer help for the nationwide maldistribution of adolescent psychiatry providers.

Is Consultation-Liaison Psychiatry 'Getting Old'? How Psychiatry Referrals in the General Hospital Have Changed over 20 Years

There is an ever-growing awareness of the health-related special needs of older patients, and Consultation-Liaison Psychiatry Services (CLPS) are significantly involved in providing such age-friendly hospital care. CLPS perform psychiatric assessment for hospitalized patients with suspected medical-psychiatric comorbidity and support ward teams in a bio-psycho-social oriented care management. Changes in features of the population referred to a CLPS over a 20-year course were analysed and discussed, especially comparing older and younger referred subjects. Epidemiological and clinical data from all first psychiatric consultations carried out at the Modena (North of Italy) University Hospital CLPS in the period 2000–2019 (N = 19,278) were included; two groups of consultations were created according to the age of patients: OV65 (consultations for patients older than 64 years) and NONOV65 (all the rest of consultations). Consultations for OV65 were about 38.9% of the total assessments performed, with an average of approximately 375 per year, vs. the 589 performed for NOV65. The number of referrals for older patients significantly increased over the 20 years. The mean age and the male/female ratio of the sample changed significantly across the years in the whole sample as well as both among OV65 and NOV65. Urgent referrals were more frequent among NOV65 and the rate between urgent/non urgent referrals changed differently in the two subgroups. The analysis outlined recurring patterns that should guide future clinical, training and research activities.

Academic Interest in Pain: Comparison of Four Specialties With Long-Standing Involvement in Pain Medicine

PURPOSE

One of the most interesting signs of growth in a medical specialty is the addition of pain medicine as a clinical subspecialty to it. The aim of this study was to analyze publication-based academic interest in pain medicine among clinical specialties with long-standing involvement in pain management.

METHODS

We assessed the activity within several specialties in the development of an academic foundation for pain medicine by measuring the frequency of the most common pain topics (1998-2017) in academic journals representing such specialties. The selection of materials for the analysis of publication-based academic interest associated with the development of pain medicine followed a three-step process: (1) Medical specialties, limited to those with accredited fellowship training in pain medicine for more than 20 years - anesthesiology, neurology, physiatry, and psychiatry; (2) Pain topics, based on the degree of topic association with the work of pain clinics - a total of 34 topics; (3) Specialty journals, mostly official journals of societies publishing articles representing all aspects of a specialty - four journals per specialty. Specialty-related academic interest was characterized in two dimensions: its breadth (the number of different topics of interest with distinctly high shares of publications) and its intensity (maximal number of publications on a particular topic).

RESULTS

According to the number of topics with a distinctly high share of articles per topic (≥ 5%), the rank order of specialties was as follows (of 34 topics): anesthesiology (22), physiatry (20), neurology (10), and psychiatry (0). Regarding comparative intensity of interest, anesthesiology has prevailing interest in 16 topics (especially in postoperative pain and pharmacologic pain treatment), physiatry in 13 topics (especially in physical methods of pain therapy), and neurology in one topic (headache disorders).

CONCLUSION

Publication-based academic interest in pain management was most intensive in two specialties, anesthesiology and physiatry, with anesthesiology being somewhat more multifaceted, especially in the methods of pain treatment.

Is grey literature essential for a better control of publication bias in psychiatry? An example from three meta-analyses of schizophrenia

Systematic reviews in mental health have become useful tools for health professionals in view of the massive amount and heterogeneous nature of biomedical information available today. In order to determine the risk of bias in the studies evaluated and to avoid bias in generalizing conclusions from the reviews it is therefore important to use a very strict methodology in systematic reviews. One bias which may affect the generalization of results is publication bias, which is determined by the nature and direction of the study results. To control or minimize this type of bias, the authors of systematic reviews undertake comprehensive searches of medical databases and expand on the findings, often undertaking searches of grey literature (material which is not formally published). This paper attempts to show the consequences (and risk) of generalizing the implications of grey literature in the control of publication bias, as was proposed in a recent systematic work. By repeating the analyses for the same outcome from three different systematic reviews that included both published and grey literature our results showed that confusion between grey literature and publication bias may affect the results of a concrete meta-analysis.

Physical Examination Skills Among Chief Residents in Psychiatry: Practices, Attitudes, and Self-Perceived Knowledge

OBJECTIVES

The authors investigated the attitudes, self-perceived competence, and the need for a dedicated curriculum on physical examination skills among chief residents in psychiatry.

METHODS

A voluntary 28-item web-based questionnaire was distributed to psychiatry chief residents in the USA between January 2019 and February 2019.

RESULTS

Of 181 chief residents, 79 (response rate, 44%) completed the online survey. The majority of chief residents want to improve their physical exam skills (64%) and believe that there should be a targeted curriculum aimed at incorporating these skills into everyday psychiatric practice (63%). However, most (57%) chief residents reported that they only conduct physical exams on a few selected patients (< 25% of the time) and almost half (48%) last used a stethoscope a year ago, if not longer. Self-perceived competence and comfort level with neurology-related exam findings was especially low: only 35% could identify discrepant neurological findings and 33% elicit Hoover's sign of leg paresis. A significant majority (86%) believed that performing a physical exam would not interfere with the therapeutic relationship.

CONCLUSIONS

Although chief residents in psychiatry believe that developing competence in physical examinations is important to their education, the current educational landscape does not support the development of these skills. Future educational strategies should focus on addressing this need.

Comfort Level and Barriers to the Appropriate Use of Clozapine: a Preliminary Survey of US Psychiatric Residents

OBJECTIVE

Clozapine is the gold standard treatment for treatment-resistant schizophrenia. Prior surveys of mental health providers have identified multiple causes for underutilization of clozapine; however, no previous survey has been conducted to assess US psychiatry residents' level of comfort in prescribing clozapine.

METHODS

A survey was sent via email to program directors of Accreditation Council for Graduate Medical Education-affiliated psychiatry residency programs requesting the survey to be distributed to current residents. The survey included questions regarding demographics, clozapine-prescribing practices, comfort levels with prescription, and perceived barriers to prescription.

RESULTS

A total of 164 psychiatric residents completed the survey, 37% PGY-1 and 2 residents and 63% PGY-3 or higher. One-third of the respondents had a clozapine clinic in their program. Only 18% of the residents felt "very" comfortable in initiating clozapine and 41% felt "somewhat" comfortable. Two main reasons for not starting clozapine were (1) side effect profile (41%) and (2) limited experience and inadequate training in clozapine use (38%). More than 4/5ths of the residents (83%) responded that they would feel more comfortable in prescribing clozapine if they were trained in a clozapine clinic. Major limitation of this study has been the small sample size, lack of representativeness, and generalization.

CONCLUSIONS

Forty-one percent of the respondents did not feel comfortable with clozapine prescription. Major concerns cited included the side effect profile as well as lack of experience and training. The majority of the respondents felt that they would be more comfortable prescribing clozapine if they had the opportunity to train in a clozapine clinic.

Impact of experience of psychiatrists and psychiatry residents regarding electronic communication and social networking on internet use patterns: a questionnaire survey for developing e-professionalism in South Korea

BACKGROUND

The development of technology, novel communication, and social networking can positively or negatively affect the therapeutic alliance between patients and psychiatrists. We conducted this study to identify Internet use patterns of psychiatrists and psychiatry residents in South Korea and to provide basic data for developing e-professionalism.

METHODS

In this questionnaire survey included a total of 250 participants, of which 195 (78%) completed the questionnaire. Questions included demographics, use of email, web searches, personal and professional use of websites and social networking, and negative and positive experiences of electronic communication and social networking. We confirmed the correlation between experience and use patterns of psychiatrists' electronic communication and social networking.

RESULTS

A total of 129 participants (66.2%) reported that they posted their personal or professional content online, 112 (57.9%) had received patients' requests through electronic communication or social networking, and 120 (61.4%) had communicated with patients via electronic communication or social networking. In total, 170 participants (87.2%) reported that they were worried about the negative consequences of using electronic communication and social networking, and 180 (92.3%) indicated they were not educated about electronic communication or social networking.

CONCLUSION

In order to reduce the negative effects of electronic communication and social networking, we need guidelines that are appropriate for the situation in South Korea. Furthermore, future research will need to identify and suggest solutions for negative experiences of electronic communication and social networking that may affect the relationship between patients and physicians.

Epileptic psychoses are underrecognized by French neurologists and psychiatrists

This study evaluates the knowledge about psychotic disorders associated with epilepsy among medical practitioners in France. A self-report questionnaire was sent, and responses of 486 participants were collected. Results showed the rate of correct responses being higher among neurologists compared to psychiatrists, respectively 70.6% and 58.3% (p < 10^-11). The highest rate of correct responses was found for the participants trained in epileptology (71%), and a regression analysis confirmed that epilepsy-training was the most influential variable. However, we found that knowledge about epileptic psychosis was imprecise among all participants: current classification was not known to most participants (77%), there were false beliefs concerning postictal confusion and psychosis (41%), and both prevalence and duration of postictal psychosis were not well-known. There is the first survey to highlight such gaps of knowledge, and hopefully lead to measures to remedy this, especially specialists such as psychiatrists, neurologists, and epileptologists who may be called upon to treat such patients.

Perceptions of Residents and Their Training Directors Regarding Wellness Education, Program Support, and Access to Depression Treatment: the DEPRESS-Ohio Study

OBJECTIVE

This study determines the extent to which residents and their program directors have discordant perceptions regarding wellness, support, and treatment opportunities for trainees. In addition, the authors examined whether psychiatry residents differed in their perceptions compared with residents in other specialties.

METHODS

Residents and their program directors from each of 10 specialties were electronically surveyed after IRB approval and giving informed consent.

RESULTS

Of 42 program directors responding, over 92% indicated they provided wellness education and programming; however, a significantly lower percentage of 822 trainees were aware of this (81.2% and 74.9%, respectively). A similar disparity existed between program directors (PDs) who knew where to refer depressed residents for help (92.9%) and residents who knew where to seek help (71%). Moreover, 83.3% of program directors believed they could comfortably discuss depression with a depressed resident, but a lower percentage of their trainees (69.1%) felt their training directors would be supportive. A significantly greater percentage of program directors (40.5%) believed seeking treatment for depression might compromise medical licensure than did residents (13.0%). Psychiatry residents were significantly more aware of wellness, support, and access than were residents from other specialties.

CONCLUSIONS

The availability of wellness education, programming, program director accessibility, and knowing where to ask for help if depressed does not seem to be adequately communicated to many residents. Moreover, program directors disproportionately see depression treatment as a risk to medical licensure compared with their residents. Psychiatry residents seem to be more aware of program director support and access to care than their colleagues.

Longitudinal analysis of dementia diagnosis and specialty care among racially diverse Medicare beneficiaries

INTRODUCTION

There is insufficient understanding of diagnosis of etiologic dementia subtypes and contact with specialized dementia care among older Americans.

METHODS

We quantified dementia diagnoses and subsequent health care over five years by etiologic subtype and physician specialty among Medicare beneficiaries with incident dementia diagnosis in 2008/09 (226,604 persons/714,015 person-years).

RESULTS

Eighty-five percent of people were diagnosed by a nondementia specialist physician. Use of dementia specialists within one year (22%) and five years (36%) of diagnosis was low. "Unspecified" dementia diagnosis was common, higher among those diagnosed by nondementia specialists (33.2%) than dementia specialists (21.6%). Half of diagnoses were Alzheimer's disease.

DISCUSSION

Ascertainment of etiologic dementia subtype may inform hereditary risk and facilitate financial and care planning. Use of dementia specialty care was low, particularly for Hispanics and Asians, and associated with more detection of etiological subtype. Dementia-related professional development for nonspecialists is urgent given their central role in dementia diagnosis and care.

Providing psychiatric healthcare to asylum seekers: reflections and challenges

BACKGROUND

According to the United Nations High Commissioner for Refugees the number of people forced to leave their home as a result of conflict, persecution, violence or human rights violations remains high with 68.5 million forcibly displaced people worldwide. Asylum seekers are vulnerable in terms of mental health but they receive very little specific psychiatric care. The purpose of this literature review is to examine current situation regarding asylum seekers' psychiatric healthcare.

SUBJECTS AND METHODS

This research was conducted using a keyword search on Medline, PubMed and Google Scholar.

RESULTS

The literature on the management of the mental health of asylum seekers focuses on the issue of post-traumatic stress disorder. There is little data on other forms of mental illness in this population. The prevalence of post-traumatic stress disorder among asylum seekers is higher than in the general population and its clinical expression is varied and often complex because it involves various vulnerability factors. Guidelines for post-traumatic stress disorder recommend cognitive behavioral therapy with, in some cases, the use of pharmacotherapy. Given the specificities of the asylum seekers' population, in many cases it is not possible to set up such therapy immediately. Asylum seekers face a number of challenges in accessing mental healthcare.

CONCLUSION

Management of the mental health of asylum seekers requires special attention and guidelines for the general population are not directly applicable to this specific population. The literature focuses on the issue of post-traumatic stress disorder. This review was not able to analyse the state of existing care offer in Belgium for managing the mental health of asylum seekers and the care pathways they take.

A systematic review of proactive psychiatric consultation on hospital length of stay

OBJECTIVE

Roughly half of general hospital patients may have a psychiatric issue that impacts care, yet most of these are not recognized during hospital admission. Proactive mental health screening offers an opportunity for timely identification and clinical attention to improve outcomes.

METHOD

We conducted a PRISMA systematic review of Pubmed, Embase, PsycINFO, and Cochrane Library for proactive models of psychiatric consultation to reduce hospital length of stay (LOS) in adult inpatients. For each study, we evaluated the level of evidence and defined the study sample, means of group allocation, screening process, interventions, and outcomes.

RESULTS

Of the 12 included studies, the 8 whose screening was informed by clinicians with mental health care expertise or whose providers were integrated with primary services reported a reduction in LOS. Two of these also reported favorable cost-benefit analyses. All positive studies represent versions of either psychiatrists embedded within medical or surgical settings or a multidisciplinary team-based model.

CONCLUSIONS

Proactive CL psychiatry with clinically-informed screening and integrated care delivery appear to reduce LOS. Further studies are needed to explore a broader range of outcomes, hospital populations beyond hospital medicine, and additional benefits of proactive integrated mental health care in the general hospital.

Trends in antidepressant prescriptions in children and young people in England, 1998-2017: protocol of a cohort study using linked primary care and secondary care datasets

INTRODUCTION

Increasing numbers of children and young people (CYP) are receiving prescriptions for antidepressants. This is the protocol of a study aiming to describe the trends and variation in antidepressant prescriptions in CYP in England, and to examine the indications for the prescriptions recorded and whether there was contact with secondary care specialists on or around the time of the first antidepressant prescription.

METHODS AND ANALYSIS

All eligible CYP aged between 5 and 17 years in 1998-2017 from the QResearch primary care database will be included. Incidence and prevalence rates of any antidepressant prescription in each year will be calculated. We will examine four different antidepressant classes: selective serotonin reuptake inhibitors, tricyclic and related antidepressants, serotonin and norepinephrine reuptake inhibitors and other antidepressants, as well as for individual drugs. Linked primary and secondary care data (hospital episode statistics) in the year before and up to 6 months after the first antidepressant prescription will be examined for CYP whose first antidepressant prescription was in 2006-2017. Whether there were records of indications and being seen by psychiatric or paediatric specialists will be identified. Trends over time and differences by region, deprivation and ethnicity will be examined using Poisson regression.

DISCUSSION

This large, population-based study will give an up-to-date picture of antidepressant prescribing in CYP and identify any variation. Understanding what indications are recorded when CYP are being prescribed antidepressants, and whether this was done in partnership with secondary care specialists, will provide evidence of whether appropriate guidelines are being followed.

Closed for Business? Using a Mixture Model to Explore the Supply of Psychiatric Care for New Patients

OBJECTIVE

To investigate the degree to which psychiatrists are accessible to new outpatients and the factors that predict whether psychiatrists will see new outpatients.

METHODS

We used administrative health data on all practicing full-time psychiatrists in Ontario, Canada, over a 5-year period (2009-2010 to 2013-2014). We used a regression model to estimate the number of new outpatients seen, accounting for case mix, outpatient volume, and psychiatrist practice characteristics.

RESULTS

Approximately 10% of full-time psychiatrists are seeing 1 or fewer new outpatients per month, and another 10% are seeing between 1 and 2 new outpatients per month. Our model identified psychiatrists in 3 distinct practice styles. One practice style (representing 29% of psychiatrists), on average, saw fewer than 2 new outpatients per month and 69 unique outpatients annually. Relative to other practice styles, they tended to see fewer patients with a previous psychiatric hospitalization and fewer patients who lived in lower income neighbourhoods.

CONCLUSIONS

Nearly 1 in 3 full-time psychiatrists in Ontario see very few new outpatients. This has implications for access to care, particularly for outpatients with newly diagnosed mental illness. It also highlights the continued need to address access issues by assessing the role of psychiatrists within the Canadian health care system.

Videoconferencing Technology to Facilitate a Pilot Training Course in Advanced Psychopharmacology for Psychiatrists

OBJECTIVE

Psychopharmacology requires practitioners to continually upgrade knowledge and skills, but attendance at live continuing medical education events presents many barriers. In addition, technology has generated new learning approaches. In response, a videoconference-based course on psychopharmacology was developed and evaluated for feasibility and acceptability. Specific goals included whether learners would engage and whether the technology would work well for both learners and instructors. Additional aims included providing guideline-concordant psychopharmacology training, enhancing patient safety, and fostering case discussion.

METHODS

The course used BlueJeans® videoconferencing technology. Each of the six weekly sessions was taught by a facilitator and a speaker. Every class incorporated a 1-h interactive didactic presentation, followed by 1 h for case reviews. Topics included six major psychiatric disorders, managing key drug interactions, and pharmacogenomics. Three types of online self-report evaluations were conducted-individual session evaluation, overall evaluation, and faculty speaker evaluation.

RESULTS

Nineteen participants enrolled, with 85% of respondents reporting course objectives were met as "very good" or "excellent." Moreover, 92% of respondents rated the course as "very good" or "excellent." Sixty percent of the faculty were "somewhat satisfied" and 40% were "extremely satisfied" with the videoconferencing tool. Qualitative responses from both participants and faculty were positive overall.

CONCLUSIONS

This course provides preliminary evidence that an online, live longitudinal course in psychopharmacology is both acceptable and effective, both for CME learners and teachers. The authors plan to disseminate this model of CME to other institutions while extending the reach of the present course to more diverse practitioners.

Factors that Affect Choice of Mental Health Provider and Receipt of Outpatient Mental Health Treatment

According to the US Department of Health and Human Services, 91 million adults live in mental health professional shortage areas and 10 million individuals have serious mental illness (SMI). This study examines how the supply of psychiatrists, severity of mental illness, out-of-pocket costs, and health insurance type influence patients' decisions to receive treatment and the type of provider chosen. Analyses using 2012-2013 MarketScan Commercial Claims data showed that patients residing in an area with few psychiatrists per capita had a higher predicted probability of not receiving follow-up care (46.4%) compared with patients residing in an area with more psychiatrists per capita (42.5%), and those in low-psychiatrist-supply areas had a higher predicted probability of receiving prescription medication only (10.2 vs 7.6%). Patients with SMI were more likely than those without SMI to obtain treatment. A $25 increase in out-of-pocket costs had marginal impact on patients' treatment choices.

[The future of psychiatrists: subquota and quota-raising in Belgium]

In Belgium, the number of medical students that can start a psychiatry residency is defined by a fixed number.<br/> AIM: To present this calculation process.<br/> METHOD: To reconstruct this process based on documents published by the planning committee, a federal committee comprised of a representation from different universities, several ministries, and Belgian communities.<br/> RESULTS: With the help of an algorithm, the expected number of psychiatrists needed in the future is calculated by the planning committee and shared to be implemented by the communities.<br/> CONCLUSION: The planning committee estimates the number of psychiatrists needed by an algorithm that uses both historical tendencies and more rapidly changing parameters. However, the incorporation of predicted epidemiological changes remains limited.

Emergency Department Discharge Outcome and Psychiatric Consultation in North African Patients

Studies in Europe have found that immigrants, compared to the local population, are more likely to seek out medical care in Emergency Departments (EDs). In addition, studies show that immigrants utilize medical services provided by EDs for less acute issues. Despite these observed differences, little is known about the characteristics of ED use by North African (NA) immigrants. The main objective of this study was to examine whether there were differences in ED discharge outcomes and psychiatric referrals between NA immigrants and Swiss nationals. A retrospective analysis was conducted using patient records from NA and Swiss adults who were admitted to the ED of the University Hospital in Bern (Switzerland) from 2013–2016. Measures included demographic information as well as data on types of admission. Outcome variables included discharge type and psychiatric referral. A total of 77,619 patients generated 116,859 consultations to the ED, of which 1.1 per cent (n = 1338) were consultations by NA patients. Compared to Swiss national patients, NA patients were younger, with a median age of 38.0 (IQR 28–51 years vs. 52.0 (IQR 32–52) for Swiss and predominantly male (74.4% vs. 55.6% in the Swiss). NA patient admission type was more likely to be “walk-in” or legal admission (7.5% vs 0.8 in Swiss,). Logistic regressions indicated that NA patients had 1.2 times higher odds (95% CI 1.07–1.40, p < 0.003) of receiving ambulatory care. An effect modification by age group and sex was observed for the primary outcome “seen by a psychiatrist”, especially for men in the 16–25 years age group, whereby male NA patients had 3.45 times higher odds (95% CI: 2.22–5.38) of having being seen by a psychiatrist. In conclusion differences were observed between NA and Swiss national patients in ED consultations referrals and outcomes, in which NA had more ambulatory discharges and NA males, especially young, were more likely to have been seen by psychiatrist. Future studies would benefit from identifying those factors underlying these differences in ED utilization.

Audit of Mental Capacity Assessment by Primary Care Physicians Versus Consultation-liaison Psychiatrists

OBJECTIVE

To review the mental capacity assessment of in-patients referred to consultation-liaison psychiatrists and to compare the assessment first made by primary care physicians.

METHODS

Medical records of in-patients who were referred to consultation-liaison psychiatrists for mental capacity assessment between May and October 2015 were retrospectively reviewed. Assessment was first made by a primary care physician; complex cases were referred to a consultation-liaison psychiatrist. Audit of each case note was conducted independently by at least two of the authors.

RESULTS

Medical records of 37 female and 26 male in-patients aged 24 to 91 (mean, 68.2) years were audited. Only 33.3% of these patients had no psychiatric diagnosis. Overall, assessments by primary care physicians were suboptimal. Assessments by consultation-liaison psychiatrists were more detailed, with documentation of mental capacity (93.7%) and psychiatric diagnosis (88.9%). Nonetheless, patient wishes and beliefs were poorly documented (19.0%), as were whether the patient had a lasting power of attorney or a court-appointed deputy (6.3%) and whether the patient had made advance care planning (0%).

CONCLUSION

Overall, mental capacity assessment was inadequately performed by primary care physicians and consultation-liaison psychiatrists. More work needs to be done to engage, educate, and empower all stakeholders involved.

[Stigmatisation of mental illness by medical students in Conakry, Guinea]

INTRODUCTION

Stigmatisation of mental illness constitutes a major problem in the development of mental healthcare programs, especially when it originates from health professionals themselves. The aim of this research is to investigate possible attitudes of stigmatisation among first and final year medical students registered at the University of Conakry faculty of medicine in Guinea-Conakry (West Africa).

METHODS

Focus group discussions identified students' attitudes and perceptions in relation to mental illness, their explanatory models, their opinions concerning traditional and modern therapeutic practices with regard to mental illness, and their interest to possibly incorporate psychiatry in their future medical practice.

RESULTS

Many students explicitly regret the stigmatisation of mental health patients, but nevertheless share the general population's prevailing attitudes of discrimination. The dominant stereotype of mental illness is that of madness, although final year medical students describe a more diverse spectrum of mental health problems. There is strong adherence to secular occult explanations of mental illness and advocacy for traditional medicine in addressing these illnesses, including among final year medical students.

DISCUSSION

No student would opt for psychiatry as a specialisation, although some expressed interest in integrating psychiatry into their future medical practice. However, this research indicates that stigmatising attitudes are not cut in stone. Under the impetus of specific teaching programmes, attitudes can evolve to create room for tolerance and compassion.

Bayesian alternatives for common null-hypothesis significance tests in psychiatry: a non-technical guide using JASP

BACKGROUND

Despite its popularity as an inferential framework, classical null hypothesis significance testing (NHST) has several restrictions. Bayesian analysis can be used to complement NHST, however, this approach has been underutilized largely due to a dearth of accessible software options. JASP is a recently developed open-source statistical package that facilitates both Bayesian and NHST analysis using a graphical interface. This article provides an applied introduction to Bayesian inference with Bayes factors using JASP.

METHODS

We use JASP to compare and contrast Bayesian alternatives for several common classical null hypothesis significance tests: correlations, frequency distributions, t-tests, ANCOVAs, and ANOVAs. These examples are also used to illustrate the strengths and limitations of both NHST and Bayesian hypothesis testing.

RESULTS

A comparison of NHST and Bayesian inferential frameworks demonstrates that Bayes factors can complement p-values by providing additional information for hypothesis testing. Namely, Bayes factors can quantify relative evidence for both alternative and null hypotheses. Moreover, the magnitude of this evidence can be presented as an easy-to-interpret odds ratio.

CONCLUSIONS

While Bayesian analysis is by no means a new method, this type of statistical inference has been largely inaccessible for most psychiatry researchers. JASP provides a straightforward means of performing reproducible Bayesian hypothesis tests using a graphical "point and click" environment that will be familiar to researchers conversant with other graphical statistical packages, such as SPSS.

Geographic Variation in the Supply of Selected Behavioral Health Providers

INTRODUCTION

In 2015, an estimated 43.4 million Americans aged 18 and older suffered from a behavioral health issue. Accurate estimates of the number of psychiatrists, psychologists, and psychiatric nurse practitioners are needed as demand for behavioral health care grows.

METHODS

The National Plan and Provider Enumeration System National Provider Identifier data (October 2015) was used to examine the supply of psychiatrists, psychologists, and psychiatric nurse practitioners. Providers were classified into three geographic categories based on their practicing county (metropolitan, micropolitan, and non-core). Claritas 2014 U.S. population data were used to calculate provider-to-population ratios for each provider type. Analysis was completed in 2016.

RESULTS

Substantial variation exists across Census Divisions in the per capita supply of psychiatrists, psychologists, and psychiatric nurse practitioners. The New England Census Division had the highest per capita supply and the West South Central Census Division had among the lowest supply of all three provider types. Nationally, the per capita supply of these providers was substantially lower in non-metropolitan counties than in metropolitan counties, but Census Division disparities persisted across geographic categories. There was a more than tenfold difference in the percentage of counties lacking a psychiatrist between the New England Census Division (6%) and the West North Central Census Division (69%). Higher percentages of non-metropolitan counties lacked a psychiatrist.

CONCLUSIONS

Psychiatrists, psychologists, and psychiatric nurse practitioners are unequally distributed throughout the U.S. Disparities exist across Census Divisions and geographic categories. Understanding this unequal distribution is necessary for developing approaches to improving access to behavioral health services for underserved populations.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

Assessing the continuum between temperament and affective illness: psychiatric and mathematical perspectives

Temperament of healthy people and mental illnesses, particularly affective disorders, have been conjectured to lie along a continuum of neurobehavioural regulation. Understanding the nature of this continuum may better inform the construction of taxonomies for both categories of behaviour. Both temperament and mental illness refer to patterns of behaviour that manifest over long time scales (weeks to years) and they appear to share many underlying neuroregulatory systems. This continuum is discussed from the perspectives of nonlinear dynamical systems theory, neurobiology and psychiatry as applied to understanding such multiscale time-series behaviour. Particular emphasis is given to issues of generativity, fungibility, metastability, non-stationarity and contextuality. Implications of these dynamical properties for the development of taxonomies will be discussed. Problems with the over-reliance of psychologists on statistical and mathematical methods in deriving their taxonomies (particularly those based on factor analysis) will be discussed from a dynamical perspective. An alternative approach to temperament based upon functionality, and its discriminative capabilities in mental illness, is presented.This article is part of the theme issue 'Diverse perspectives on diversity: multi-disciplinary approaches to taxonomies of individual differences'.

[Psychiatric readmissions: individual and organizational factors]

BACKGROUND

Psychiatric readmission often constitutes a criterion to assess the effects of various therapies, as well as the impact of organizational changes in the healthcare system. It is used to characterize relapse or decompensation. The purpose of this study was to determine readmission rates and identify individual and organizational factors associated with significant variations in these rates.

METHODS

Adult psychiatric readmissions were identified from the full-time hospital stays registered in psychiatric wards in 2011-2012 in the Nord and Pas-de-Calais departments of France, available in the medical the RimP psychiatric admission database. Readmission rates for various follow-up periods after discharge were measured by Kaplan-Meier survival analysis and multivariate analysis was conducted using the Cox proportional hazards model.

RESULTS

Approximately 30,000 adults were hospitalized full-time in psychiatric units of the region during the study period. The 24-month readmission rate was 51.6% (95%CI: 50.8-52.3%). The Cox model showed that a diagnosis of schizophrenia (F2 - HR = 1.72 - 95%CI: 1.61-1.84 - p < 0.001) and personality disorder (F6 - HR = 1.45 - 95%CI: 1.32-1.58 - p < 0.001) was associated with a higher readmission rate. Readmission rates were higher among dependent patients in non-profit private hospitals.

CONCLUSION

Psychiatric readmission is a very frequent event and is linked to organizational as well as individual factors.

Awareness of Medical Fitness to Drive Guidelines among Occupational Physicians and Psychiatrists

Irrespective of national guidelines for medical fitness to drive, this study investigated the cumulative expert wisdom of clinicians regarding minimum periods of driving cessation required for patients suffering from conditions that can impair driver capability. Occupational Physicians (196) and Psychiatrists (103) completed an online questionnaire. For private motorists, the modal response for anxiety and depression favoured clinical discretion, followed by three month cessations for hypomania, acute psychosis, schizophrenia and alcohol dependence and six weeks for alcohol misuse/dependence. For professional drivers the modal value for anxiety and depression was three months, rising to six months for hypomania, psychosis and schizophrenia and 12 months for both alcohol misuse/dependence. Chi-square test results indicated statistically significant differences in clinical opinion between Occupational Physicians and Psychiatrists regarding driving cessation times for drivers suffering from psychiatric and alcohol misuse conditions except for alcohol dependence. Further studies are warranted to investigate these issues in more depth.

Implementation and Utilisation of Telepsychiatry in Ontario: A Population-Based Study

OBJECTIVE

Rural areas in Ontario have fewer psychiatrists, making access to specialist mental health care challenging. Our objective was to characterise psychiatrists delivering and patients receiving telepsychiatry in Ontario and to determine the number of patients who accessed a psychiatrist via telepsychiatry following discharge from psychiatric hospitalisation.

METHOD

We conducted a serial panel study to evaluate the characteristics of psychiatrists providing telepsychiatry from April 2007 to March 2013. In addition, we conducted a cross-sectional study for fiscal year 2012-2013 to examine telepsychiatry patient characteristics and create an in-need patient cohort of individuals with a recent psychiatric hospitalisation that assessed if they had follow-up with a psychiatrist in person or through telepsychiatry within 1 year of discharge.

RESULTS

In fiscal year 2012-2013, a total of 3801 people had 5635 telepsychiatry visits, and 7% ( n = 138) of Ontario psychiatrists provided telepsychiatry. Of the 48,381 people identified as in need of psychiatric care, 60% saw a local psychiatrist, 39% saw no psychiatrist, and less than 1% saw a psychiatrist through telepsychiatry only or telepsychiatry in addition to local psychiatry within a year. Three northern regions had more than 50% of in-need patients fail to access psychiatry within 1 year.

CONCLUSIONS

Currently, relatively few patients and psychiatrists use telepsychiatry. In addition, patients scarcely access telepsychiatry for posthospitalisation follow-up. This study, which serves as a preliminary baseline for telepsychiatry in Ontario, demonstrates that telepsychiatry has not evolved systematically to address need and highlights the importance of system-level planning when implementing telepsychiatry to optimise access to care.

Training Experiences of Family Medicine Residents on Behavioral Health Rotations

BACKGROUND AND OBJECTIVES

Although accreditation guidelines for residency in family medicine include behavioral health curriculum, little is known about resident learning activities in real world training. Our study explored residents' perceptions about and exposure to specific activities during their behavioral health rotations.

METHODS

Family medicine residents (N=84) recruited via faculty list serves completed a survey about their experiences during behavioral health rotations. The survey included quantitative Likert scale questions, along with open-ended questions on which a qualitative content analysis was performed.

RESULTS

Open-ended responses indicated that many residents receive constructive observation and collaboration opportunities during their training month. However, residents wanted more time to practice behavioral health skills beyond the rotation, more practice in psychotherapy skills, and additional education on medication management. Most residents (62%) received either limited or no training in couples or family therapy during their behavioral health rotation. Residents who reported more behavioral health knowledge gain during the rotation also reported higher self-perceived competency using Motivational Interviewing (M=3.82, P<.01).

CONCLUSIONS

While family medicine as a discipline is based on the biopsychosocial model of care, residents reported deficits in education about family systems. Residents desire additional opportunities to learn psychotherapy techniques and practice counseling skills. Family medicine residency programs and faculty may consider supplementing their core behavioral curriculum to include these content areas.

Mental health literacy survey of non-mental health professionals in six general hospitals in Hunan Province of China

BACKGROUND

Mental illness has brought great economic burden related to misdiagnosis by non-mental health professionals in general hospitals. The aim of this study was to explore non-mental health professionals' conceptions related to the identification of mental illness and perceived treatments, first aid and prognosis.

METHODS

In 2014-2015, we presented 1123 non-mental health professionals from six general hospitals in Hunan Province with one of three vignettes describing a person with schizophrenia, depression, or generalized anxiety disorder. Identification rates, beliefs about various interventions, best methods, and the prognosis with or without treatment were measured.

RESULTS

Less than 60% of the non-mental health professionals could identify the mental disorders correctly. Psychiatrists and psychologists were considered to be the people who would be most helpful in all vignettes. Over 70% of participants identified the correct medication for each vignette. Participants gave higher ratings to lifestyle interventions than to psychological and medical interventions, especially in the depression and generalized anxiety disorder vignettes. For the question about how the person could best be helped, about half of the participants rated listening or talking with the person more highly than accompanying the person to professional help or encouraging the person to visit a psychiatrist or psychologist. Participants believed that, with professional help, the people in the vignettes would fully recover but that problems would probably reoccur and that, without professional help, the people described would get worse.

CONCLUSIONS

The beliefs that non-mental health professionals hold about mental disorders are inadequate to provide appropriate help. There is an urgent need for mental health education campaigns to improve non-mental health professionals' mental health knowledge in mainland China in order to provide better support for mental health service users.

Knowledge and Attitude Towards Pharmacological Management of Acute Agitation: A Survey of Psychiatrists, Psychiatry Residents, and Psychiatric Nurses

OBJECTIVE

The authors compared the current knowledge and attitude of psychiatrists, psychiatry residents, and psychiatric nurses towards the pharmacological management of acute agitation.

METHODS

Questionnaires were electronically distributed to all attending psychiatrists, psychiatry residents, and psychiatric nurses who were either employed by the University Department of Psychiatry and Behavioral Sciences or were staff at a 250-bed affiliated Psychiatric Hospital. Where possible, Fisher's exact test was used to compare responses to questions based on designation.

RESULTS

Of the 250 questionnaires distributed, 112 were returned (response rate of 44.8%), of which 64 (57.1%) were psychiatric nurses, 27 (24.1%) were attending psychiatrists, and 21 (18.8%) were psychiatry residents. A significantly higher percentage of attending psychiatrists and psychiatric nurses compared to psychiatry residents thought that newer second- generation antipsychotics (SGAs) are not as effective as older first-generation antipsychotics (FGAs) for managing acute agitation (55.6, 48.4, and 9.5% respectively, p = 0.008). The combination of intramuscular haloperidol, lorazepam, and diphenhydramine was the most preferred option chosen by all designations for the psychopharmacological management of severe agitation. Furthermore, a larger percentage of the psychiatric nurses, in comparison to attending psychiatrists, also chose the combination of intramuscular chlorpromazine, lorazepam, and diphenhydramine as an option for managing severe agitation; no psychiatry resident chose this option.

CONCLUSION

Knowledge of evidence-based psychopharmacological management of agitation differs among attending psychiatrists, psychiatry residents and psychiatric nurses. Although the management of agitation should be individualized and context specific, monotherapy should be considered first where applicable.

Residents' and Fellows' Knowledge and Attitudes About Eating Disorders at an Academic Medical Center

OBJECTIVE

This study examined physician residents' and fellows' knowledge of eating disorders and their attitudes toward patients with eating disorders.

METHODS

Eighty physicians across disciplines completed a survey. The response rate for this survey across disciplines was 64.5 %.

RESULTS

Participants demonstrated limited knowledge of eating disorders and reported minimal comfort levels treating patients with eating disorders. Psychiatry discipline (p = 0.002), eating disorder experience (p = 0.010), and having ≥4 eating disorder-continuing medical education credits (p = 0.037) predicted better knowledge of anorexia nervosa but not bulimia nervosa. Psychiatry residents (p = 0.041), and those who had treated at least one eating disorder patient (p = 0.006), reported significantly greater comfort treating patients with eating disorders.

CONCLUSION

These results suggest that residents and fellows from this sample may benefit from training to increase awareness and confidence necessary to treat patients with eating disorders. Sufficient knowledge and comfort are critical since physicians are often the first health care provider to have contact with patients who have undiagnosed eating disorders.

Medical School Factors Associated with Higher Rates of Recruitment into Psychiatry

OBJECTIVE

The medical school a student attends appears to be a factor in whether students eventually match into psychiatry. Knowledge of which factors are associated with medical schools with higher recruitment rates into psychiatry may assist in developing strategies to increase recruitment.

METHODS

Psychiatry leaders in medical student education in the 25 highest and lowest recruiting US allopathic schools were surveyed concerning various factors that could be important such as curriculum, educational leadership, and presence of anti-psychiatry stigma. The relationship between the survey results of high recruiting schools versus those of low recruiting schools was evaluated using Mann-Whitney U tests.

RESULTS

Factors significantly associated (p < .05) with higher recruiting schools included better reputation of the psychiatry department and residents, perceived higher respect for psychiatry among non-psychiatry faculty, less perception that students dissuaded other students from pursuing psychiatry, and longer clerkship length.

CONCLUSIONS

Educational culture and climate factors may have a significant impact on psychiatry recruitment rates. Clerkship length was associated with higher recruiting schools, but several previous studies with more complete samples have not shown this.

The Role of Regional Conferences in Research Resident Career Development: The California Psychiatry Research Resident Retreat

OBJECTIVE

For psychiatry research resident career development, there is a recognized need for improved cross-institutional mentoring and networking opportunities. One method to address this need is via regional conferences, open to current and recently graduated research residents and their mentors. With this in mind, we developed the biennial California Psychiatry Research Resident Retreat (CPRRR) and collected feedback from participants to 1) Assess resident satisfaction, 2) Determine the utility of the retreat as a networking and mentorship tool, and 3) Identify areas for improvement.

METHODS

We gathered survey data from resident attendees at the two first CPRRRs. We analyzed the data to look for trends in satisfaction as well as areas that need improvement.

RESULTS

Thirty-two residents from five California training programs attended the CPRRR in 2013 while 33 attended from six programs in 2015. The residents were from all years of training, but concentrated in their second and third years. Approximately 41% and 49% of the attendees were female and 53% and 39% had an MD/PhD in 2013 and 2015, respectively. Twenty-four and 32 residents provided anonymous feedback in 2013 and 2015, respectively. Mean feedback scores were very high (> 4/5) for overall satisfaction, peer- and faculty-networking, the keynote speaker and the flash talks for both years. Mean feedback scores for the ethics debates and mentoring sessions were somewhat lower (≤ 4/5), however, both showed significant improvement from 2013 to 2015.

CONCLUSION

The CPRRRs appear to be an effective mechanism for providing psychiatry research residents with a meaningful cross-institutional opportunity for networking and mentorship. Feedback-driven changes to the CPRRRs improved participant satisfaction for several components of the conference. Future efforts will be aimed at broadening mentorship and networking opportunities, optimizing teaching approaches for research ethics, and considering different feedback-gathering approaches to allow for improved longitudinal follow-up and subgroup analysis.

Undergraduate Neuroscience Majors: A Missed Opportunity for Psychiatry Workforce Development

OBJECTIVE

This study sought to determine whether and to what extent medical students with an undergraduate college major in neuroscience, relative to other college majors, pursue psychiatry relative to other brain-based specialties (neurology and neurosurgery) and internal medicine.

METHODS

The authors analyzed data from AAMC matriculation and graduation surveys for all students who graduated from US medical schools in 2013 and 2014 (n = 29,714). Students who majored in neuroscience, psychology, and biology were compared to all other students in terms of their specialty choice at both time points. For each major, the authors determined rates of specialty choice of psychiatry, neurology, neurosurgery, and, for comparison, internal medicine. This study employed Chi-square statistic to compare odds of various specialty choices among different majors.

RESULTS

Among medical students with an undergraduate neuroscience major (3.5% of all medical students), only 2.3% preferred psychiatry at matriculation, compared to 21.5% who chose neurology, 13.1% neurosurgery, and 11% internal medicine. By graduation, psychiatry specialty choice increased to 5.1% among neuroscience majors while choice of neurology and neurosurgery declined. Psychology majors (OR = 3.16, 95% CI 2.60-4.47) but not neuroscience majors (OR 1.28, 0.92-1.77) were more likely than their peers to choose psychiatry.

CONCLUSIONS

Psychiatry struggles to attract neuroscience majors to the specialty. This missed opportunity is an obstacle to developing the neuroscience literacy of the workforce and jeopardizes the neuroscientific future of our field. Several potential strategies to address the recruitment challenges exist.

Risk and Resilience Factors Associated with Resident Burnout

OBJECTIVE

We investigated hypothesized risk and resilience factors and their association with burnout in first year medicine and psychiatry residents at an urban teaching hospital in order to help guide the development of interventions targeted at reducing burnout.

METHODS

We administered the Maslach Burnout Inventory (MBI), Perceived Stress Scale-10, Functional Assessment of Chronic Illness Therapy-Fatigue Scale, Penn State Worry Questionnaire, Patient Health Questionnaire-9 (depression symptoms), Revised Life Orientation Test (optimism), Self-Efficacy Questionnaire, Cognitive and Affective Mindfulness Scale, Interpersonal Reactivity Index Perspective-Taking Scale (empathy), and Measure of Current Status-Part A to first year medicine and psychiatry residents prior to initiation of clinical rotations in June.

RESULTS

The response rate was 91 % (68 of 75 residents). Nineteen respondents (28 %) met criteria for burnout as measured by the MBI. Residents with burnout scored higher on self-report measures assessing perceived stress (Cohen's d = 0.97; p = 0.004), fatigue (d = 0.79; p = 0.018), worry (d = 0.88; p = 0.0009), and depression symptoms (d = 0.84; p = 0.035) and scored lower on questionnaires assessing mindfulness (d = -0.63; p = 0.029) and coping ability (d = -0.79; p = 0.003).

CONCLUSIONS

In a cross-sectional assessment using self-report measures, we found that nearly a third of first year residents prior to starting their internships experience burnout. They exhibit lower levels of mindfulness and coping skills and higher levels of depression symptoms, fatigue, worry, and stress. These preliminary findings should encourage programs to initiate and study curricula that combine mindfulness and self-awareness coping strategies to enhance or protect against burnout as well as cognitive behavioral coaching strategies to offset symptoms of burnout when present.

Cross-sectional survey on defensive practices and defensive behaviours among Israeli psychiatrists

OBJECTIVE

Psychiatry is a low-risk specialisation; however, there is a steady increase in malpractice claims against psychiatrists. Defensive psychiatry (DP) refers to any action undertaken by a psychiatrist to avoid malpractice liability that is not for the sole benefit of the patient's mental health and well-being. The objectives of this study were to assess the scope of DP practised by psychiatrists and to understand whether awareness of DP correlated with defensive behaviours.

METHODS

A questionnaire was administered to 213 Israeli psychiatry residents and certified psychiatrists during May and June 2015 regarding demographic data and experience with malpractice claims, medicolegal literature and litigation. Four clinical scenarios represented defensive behaviours and reactions (feelings and actions) to malpractice claims.

RESULTS

Forty-four (20.6%) certified psychiatrists and four (1.9%) residents were directly involved in malpractice claims, while 132 (62.1%) participants admitted to practising DP. Residents acknowledged the practice of DP more than did senior psychiatrists (p=0.038).Awareness of DP correlated with unnecessary hospitalisation of suicidal patients, increased unnecessary follow-up visits and prescribing smaller drug dosages than required for pregnant women and elderly patients.

CONCLUSIONS

This study provides evidence that DP is well established in the routine clinical daily practice of psychiatrists. Further studies are needed to reveal whether DP effectively protects psychiatrists from malpractice suits or, rather, if it impedes providing quality psychiatric care and represents an economic burden that leads to more harm for the patient.

Physician Office Visits for Attention-deficit/Hyperactivity Disorder in Children and Adolescents Aged 4-17 Years: United States, 2012-2013

Data from the National Ambulatory Medical Care Survey •During 2012-2013, an estimated annual average of 6.1 million physician office visits were made by children aged 4-17 years with a primary diagnosis of attention-deficit/hyperactivity disorder (ADHD). •The ADHD visit rate among children aged 4-17 years was more than twice as high for boys (147 per 1,000 boys) as for girls (62 per 1,000 girls). •Central nervous system stimulant medications were provided, prescribed, or continued at about 80% of ADHD visits among children aged 4-17 years. •Among ADHD visits by children aged 4-17 years, 29% included a diagnostic code for an additional mental health disorder. •A total of 48% of visits for ADHD by children aged 4-17 years were with pediatricians, 36% were with psychiatrists, and 12% were with general and family practitioners. Attention-deficit/hyperactivity disorder (ADHD) is one of the most commonly diagnosed neurobehavioral disorders of childhood (1-3). ADHD is characterized clinically by inattention and/or hyperactivity-impulsivity that interferes with functioning or development (4). This report describes the rate and characteristics of physician office visits by children aged 4-17 years with a primary diagnosis of ADHD. Four years of age was chosen as the lower limit because the American Academy of Pediatrics guidelines for the diagnosis and treatment of ADHD begin at this age (5).

The Influence of Genotype Information on Psychiatrists' Treatment Recommendations: More Experienced Clinicians Know Better What to Ignore

BACKGROUND

This study applies attribute nonattendance to medical decision making. We aimed to demonstrate how this type of analysis can be used in medical decision making to assess whether psychiatrists were influenced in their treatment recommendations by information on the genotype of a patient, despite knowing the patient's response to treatment as measured by the Positive and Negative Syndrome Scale. A patient's genetic information may be used to predict their response to therapy; such information, however, becomes redundant, and should not influence decisions, once a clinician knows the patient's actual response to treatment.

METHODS

Sixty-seven psychiatrists were presented with patients' pre- or post-treatment scores on the Positive and Negative Syndrome Scale for two hypothetical treatments for schizophrenia. Psychiatrists were also informed whether the patient possessed a genotype linked to hyper-responsiveness to one of the treatments, and were asked to recommend one of these two treatments. Attribute nonattendance assessed whether the information on genotype influenced psychiatrists' treatment recommendations.

RESULTS

Years of experience predicted whether psychiatrists were influenced by the genetic information. Psychiatrists with 1 year or less of experience had a 46% probability of considering genetic information, whereas psychiatrists with at least 15 years of experience had a lower probability (7%).

CONCLUSIONS

Psychiatrists and other clinicians should be cautious about allowing a patient's genetic information to carry unnecessary weight in their clinical decision making.