Current Psychiatry Reviews - Volume 6, Issue 3, 2010

The Residency Requirements Committee of the ACGME recommends that psychiatric residents receive training in cognitive behavioral psychotherapy (CBP). Despite these recommendations, some training programs are slow to implement these requirements and many struggle to develop didactic and clinical curricula to meet these criteria. This article provides a model for training psychiatry residents in cognitive behavioral therapy based on the extant literature. Literature on training psychiatrists and other mental health professionals in CBT is reviewed. A conceptual template representing declarative, procedural, and self-reflective knowledge domains is also presented. Characteristics of good candidates for CBP training are described. Ways of assessing competencies and training outcomes are discussed. Finally, the article concludes with the presentation of a training paradigm in CBP for psychiatrists.

Most of the psychopharmaceuticals used in children and adolescents have not gone through the clinical trials process; only slightly more have had research studies accomplished in this age group, particularly in younger children. Given the pressure to treat mood and behavioral disorders early, many of the medication decisions we make are based on experiences with adults. Therefore, it is prudent to review the potential problems involved in pediatric clinical research particularly as it relates to psychiatry. In this article we will examine current FDA and IRB policies, discuss the ethical issues involved in recruiting children and adolescents for these studies, as well as discuss reluctance of parents and their children to participate in clinical trials. This will be based on a long history of academic clinical trial participation at LSUHSC in Shreveport, LA. Awareness of these issues will hopefully facilitate greater research in our younger patients, leading to improved treatment options for mental illnesses.

A systematic review of the literature on the prevalence, theories and correlates of child labor was done with emphasis on mental health. The methodologies of these literatures are variable in their strength and weakness. Some surveys are intensive and informative. Exploitation of young children's labor is extensive in developing countries such as Ethiopia, where an estimated every 4th under 15 year old is a child laborer. This review further highlights why children end up in the job market, and what they wish to do in the future. Relevant recommendations to policy makers on appropriate and streamlined education, as well as the need for further longitudinal and intervention oriented research, capacity building for parents and further advice is given.

Objective: Electroconvulsive therapy (ECT) is effective and generally safe in depression. Its effectiveness and side effects are suggested to be related to the electrical stimulus administered relative to the seizure threshold. Since aging seems to raise the seizure threshold in ECT, we reviewed the literature for evidence correlating advanced age and seizure threshold, and for hypotheses explaining why seizure thresholds might raise with age. Methods: Pubmed, PsychINFO, three standard works on ECT, and cross-references were searched for studies investigating seizure thresholds and/or associated factors in elderly depressed patients. Results: A total of 406 possibly relevant articles were found, of which 27 studies could be included. One very recently published study was included afterwards because of its significance. Aging was moderately associated with a raised initial seizure threshold with correlation coefficients ranging from 0.30 to 0.64 (p<0.05). Also, seizure thresholds in elderly patients were more likely to raise during the ECT course. Reported hypotheses for these clinical phenomena include a decrease of neuroexcitability, changes in morphologic and functional characteristics of the brain, somatic comorbidity, and concomitant medication use. Conclusion: To optimize ECT in elderly patients, hypotheses and suggestions for further research are proposed regarding the moderate correlation between advanced age and initial seizure threshold and the rise in seizure threshold during the ECT course.

Delirium in older patients is a common problem, whether patients are seen in a community setting, in a hospital for medical or surgical intervention or in an intensive care unit. Evaluation of elderly patients with confusion is challenging and in delirium several aspects of cognition, including perception, mental data processing and memory, must be considered. Delirium is thought to result from imbalances in cholinergic, dopaminergic and other neurotransmitter systems. It may manifest as a hyperactive, a hypoactive or a mixed state that fluctuates over time and requires a low threshold for investigation and a high index of suspicion for diagnosis. Once the presence of delirium has been established management strategies include treating any precipitating events, modifying potential risk factors and reassuring and reorienting the patient. Accurate identification and management of delirium in the elderly is important because delirium is associated with cognitive impairment and with increases in both morbidity and mortality. This review will discuss the variable presentations of delirium in the elderly, a diagnostic approach to acute confusion in the elderly, the acute management of delirium and the prognostic implications of delirium in this population.

Obsessive-compulsive disorder (OCD) is characterized by recurrent, distressing obsessions and repetitive compulsive behaviors or mental rituals frequently performed to reduce the distress associated with the obsessions. This paper reviews maladaptive and adaptive coping responses used by individuals with OCD, including compulsions as an avoidant coping response, psychotherapeutic and pharmacological treatments, social and family support, lifestyle changes, and stress management. Although several gaps in the extant literature on coping with OCD were identified, a considerable body of research supports the use of cognitive-behavioral therapy (CBT) with exposure and response prevention (E/RP) as an effective therapeutic technique for teaching long-lasting coping skills. Increased research is needed in the role of social support, exercise and dietary changes, and stress management skills on daily functioning in individuals with OCD. Implications and recommendations for future research are discussed.

Over the century, many studies have proposed an association between madness and kin advantages. The first study focusing specifically on reproductive rates among persons suffering from schizophrenia and their relatives was published in 1959. Currently, there are 62 studies of that kind indexed in the main scientific databases, most of which confirm the existence of kin advantages after one generation. Considering that picture, this brief review explores the data of the most recent study of the kind, in order to discuss the percentage of advantage after two generations. Results: The advantage after two generations is considerably lower than in the first generation, although it should not be dismissed. However, it may be biased by the association between schizophrenia and economic status, since low economic status predicts both increased risks of schizophrenia and higher reproductive rates in several different regions of the world. Furthermore, the importance of de novo mutations, copy number variations and other sporadic genetic (and epigenetic) events, which may take part in the etiology of a significant portion of the cases of schizophrenia, presents an indirect challenge to the hypothesis of kin advantages.

Our primary objective was to determine the continuing medical education needs of family physicians involved in the Transition into Primary Care Psychiatry (TIPP) program and secondly to assess fulfillment of Canadian Medical Education Directives for Specialists (CanMEDS) roles by TIPP associated family physicians. Family physicians were asked about educational needs, comfort levels, attitudes and beliefs towards mental illness, and perceptions of supports that could enhance the management of patients with enduring mental illnesses. Patients were asked for feedback assessing the patient-family physician relationship. Of the 25 (71%) responses received from family physicians all suggested areas for improving primary mental health care knowledge were considered important, Media/Video presentation was the least preferred CME format. They do not believe they have enough training or time to adequately address their patients' mental health needs and collaborative supports for mental health care were preferred. The 37 (77%) responses from patients revealed a need for greater communication from family physicians; however, the overall level of satisfaction with treatment from TIPP family physicians was high. In conclusion, various topics and interactive formats should be offered in CME programs with particular attention paid to the time constraints of the primary care setting. Opportunities should be sought enhancing CME with collaborative care practices. TIPP associated primary care physicians are perceived to deliver satisfactory services by most mental health patients across all CanMED domains; areas of improvement largely revolve around communication in various contexts.

Depression in not uncommon in late life. Psychotic depression, a more severe form of depression is more common in late life than younger patients. Data indicate that approximately 25% of patients with depression in late life present with psychotic symptoms. In this review, we systematically searched four main databases; EMBASE, PsychINFO, Medline and Cochrane Collaboration on the pharmacotherapy of late life depression with psychotic features. Data for the treatment of psychotic depression in late life are scares although available evidence indicates efficacy for antidepressants, antipsychotic medications and mifepristone and electroconvulsive therapy. Based on the available evidence, we have provided a guideline for the appropriate treatment of this important disorder thus preventing undue suffering to the patients and their families.

Adolescence is a period of heightened exploration, emotional and physical change. During this time, engagement in risk behaviours occurs often, affecting physical, mental and social health and well-being. Risk factors can include experimentation with substances and may lead to social and legal problems, disability and accidental death. We searched CINAHL, PsycINFO, ERIC, Medline, Social Policy & Practice and PubMed to identify studies that measured child maltreatment (witnessing domestic violence, emotional maltreatment, neglect, physical and sexual abuse) and the use/abuse of substances (nicotine (cigarette smoking) alcohol and a variety of drugs) in community and school samples. Thirty-five articles comprising 31 studies met inclusion criteria. The majority of included studies identified an association, with increased risk of substance use/abuse among youth with history of child maltreatment. Physical and sexual abuse and alcohol use/abuse were most often measured. The magnitude of the association varied by type of maltreatment and type of substances: sexual abuse and (a) nicotine (odds ratio (OR) 0.9-4.2); (b) alcohol (OR 1.4-5.2) and (c) drugs (OR 1.0-8.6); physical abuse and (a) nicotine (OR 1.8-6.1); (b) alcohol (OR 0.8-8.9) and (c) drugs (OR 1.8-20.4); neglect and alcohol (OR 1.2-21.2); emotional maltreatment and (a) nicotine (OR 1.4); (b) alcohol (OR 1.5) and (c) drugs (OR 1.4); and witnessing domestic violence and (a) nicotine (OR 1.4-2.2); (b) and alcohol (OR 1.4-1.9). The results are examined and implications for research and intervention are discussed.