Caring Contacts to Reduce Psychiatric Morbidity Following Hospitalization During the COVID-19 Pandemic: A Pilot Randomized Controlled Trial

OBJECTIVES

Caring Contacts are an emerging intervention that aims to reduce distress and suicide risk after acute psychiatric care. This trial aimed to determine whether, during a pandemic, there was any evidence that the mental health benefits and reduction in suicidal ideation (SI) associated with delivering Caring Contacts to recently discharged psychiatric patients were greater than a control communication. The secondary objective was to identify whether the predicted benefits were greater among people living alone or those diagnosed with depression.

METHOD

A single-site pilot randomized clinical trial (n = 100), with patients recruited from the adult Inpatient Psychiatry Unit at Sunnybrook Health Sciences Centre, Toronto, Canada between August 2020 and May 2021. Participants were randomized (1:1) to the Caring Contact or control group. Participants received three Caring Contact or control communications via email or mail (on days 4, 21, and 56 post-discharge). Mental health symptoms were assessed using the self-report Hopkins Symptom Checklist-25 (HSCL-25) scores at discharge (baseline) and when participants received each communication. Analysis of variance was used for the primary comparisons and exploratory analyses for subgroups.

RESULTS

Both groups experienced a significant worsening of mental health symptoms at all time points post-discharge relative to baseline. There were no significant differences between groups at any time point, however, on day 4 there was a 24.2% and 72.6% attenuated worsening in the Caring Contact group compared to the control group for total symptom severity and SI, respectively. There was no significant interaction effect for the depression subgroup or those living alone.

CONCLUSIONS

While this pilot study was not powered to identify significant differences between groups, results are indicative of feasibility and acceptability of the intervention and provide some indication that Caring Contacts may have benefited patients in the days following discharge, supporting the need for larger-scale trials. The study was registered with clinicaltrials.gov (study ID NCT04456062).

Treatment-resistant major depressive disorder: Canadian expert consensus on definition and assessment

BACKGROUND

Treatment-resistant depression (TRD) is a debilitating chronic mental illness that confers increased morbidity and mortality, decreases the quality of life, impairs occupational, social, and offspring development, and translates into increased costs on the healthcare system. The goal of this study is to reach an agreement on the concept, definition, staging model, and assessment of TRD.

METHODS

This study involved a review of the literature and a modified Delphi process for consensus agreement. The Appraisal of Guidelines for Research & Evaluation II guidelines were followed for the literature appraisal. Literature was assessed for quality and strength of evidence using the grading, assessment, development, and evaluations system. Canadian national experts in depression were invited for the modified Delphi process based on their prior clinical and research expertize. Survey items were considered to have reached a consensus if 80% or more of the experts supported the statement.

RESULTS

Fourteen Canadian experts were recruited for three rounds of surveys to reach a consensus on a total of 27 items. Experts agreed that a dimensional definition for treatment resistance was a useful concept to describe the heterogeneity of this illness. The use of staging models and clinical scales was recommended in evaluating depression. Risk factors and comorbidities were identified as potential predictors for treatment resistance.

CONCLUSIONS

TRD is a meaningful concept both for clinical practice and research. An operational definition for TRD will allow for opportunities to improve the validity of predictors and therapeutic options for these patients.

Compassion Fatigue in Surgical Trainees

OBJECTIVE

Compassion fatigue (CF) is the profound sense of emotional exhaustion that care providers can experience as the result of helping others in distress. CF can contribute to burnout (BO), depression, and stress-related illness. While surgeons and surgical trainees may be at high risk for developing CF, it has not been adequately characterized or explored in this population. The objective of this study was to examine the prevalence and impact of CF in surgical trainees with a view to inform a management strategy.

STUDY DESIGN AND SETTING

A mixed method study was conducted using survey and interview methods. An email survey including the Professional Quality of Life Scale Version 5, an instrument to assess CF, was sent to all trainees in the Department of Surgery at the University of Toronto. Survey data were analyzed descriptively and using one-sample t tests. Semistructured interviews were conducted with volunteered trainees. Data collection and analysis occurred iteratively and inductively using the constant comparison method.

RESULTS

One hundred fifteen trainees completed the survey representing a 47% response rate. Ninety-nine respondents (40.7%) completed the Professional Quality of Life Scale tool. The mean score on the compassion satisfaction subscale was 36.9 (SD 6.7), on the BO subscale was 26.2 (SD 5.6), and on the secondary traumatic stress (STS) subscale was 21.2 (SD 6.3). The mean on the compassion satisfaction subscale was not statistically different from the population mean (p = 0.22). The means for the BO and STS scales were statistically higher in our study sample compared to the normative data (p < 0.0001 for each). Thematic qualitative findings indicated trainees experienced CF symptoms. Participants described systemic barriers to mitigating CF including workload and a cultural expectation to be unemotional at work.

CONCLUSION

Surgical trainees report high levels of BO and STS and currently use informal coping strategies outside of their academic and hospital environments. Trainees are likely to welcome and benefit from an organized response to support their emotional health when facing difficult patient encounters.

Assessment and Management of Posttraumatic Stress Disorder

PURPOSE

The goal of this article is to increase clinicians' understanding of posttraumatic stress disorder (PTSD) and improve skills in assessing risk for and diagnosing PTSD. The importance and sequelae of lifetime trauma burden are discussed, with reference to trends in prevention, early intervention, and treatment.

RECENT FINDINGS

PTSD has different clinical phenotypes, which are reflected in the changes in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. PTSD is almost always complicated by comorbidity. Treatment requires a multimodal approach, usually including medication, different therapeutic techniques, and management of comorbidity. Interest is growing in the neurobiology of childhood survivors of trauma, intergenerational transmission of trauma, and long-term impact of trauma on physical health. Mitigation of the risk of PTSD pretrauma in the military and first responders is gaining momentum, given concerns about the cost and disability associated with PTSD. Interest is also growing in screening for PTSD in medical populations, with evidence of improved clinical outcomes. Preliminary research supports the treatment of PTSD with repetitive transcranial magnetic stimulation.

SUMMARY

PTSD is a trauma-related disorder with features of fear and negative thinking about the trauma and the future. Untreated, it leads to ongoing disruption of life due to avoidance, impaired vocational and social functioning, and other symptoms, depending on the phenotype. Despite a theoretical understanding of underlying mechanisms, PTSD remains challenging to treat, although evidence exists for benefit of pharmacologic agents and trauma-focused therapies. A need still remains for treatments that are more effective and efficient, with faster onset.

What do I do? Developing a competency inventory for postgraduate (residency) program directors

BACKGROUND

Few new Residency Program Directors (PD) are formally trained for the demands and responsibilities of the leadership aspect of their role. Currently, there are no comprehensive frameworks that describe specific leadership competencies that can inform PD self-reflection or faculty development.

METHODS

The authors developed a Postgraduate Program Director Competency Inventory (PPDCI) in order to frame the performance of PDs for a multisource feedback (MSF) program. The development of the PPDCI occurred in five phases which involved: development of an initial inventory, implementation of a key informant survey of national opinion leaders, execution of a validity survey with postgraduate education leaders and committee members and implementation of a further refined inventory with 17 PD and 147 raters as part of a pilot MSF program.

OUTCOMES

Five distinct domains of leadership competence were identified which included: Communication and relationship management, leadership, professionalism and self-management, environmental engagement, and management skills and knowledge. The content validity of the PPDCI was endorsed by 85% of the key informants. The validity survey indicated strong endorsement of the PPDCI domains and recognition of its utility for both orientation of new PD as well as a frame for self-assessment. The pilot MSF program yielded a further refined and reduced inventory of 26 items of competence as well as recommendations for its utility.

CONCLUSIONS

Use of this leadership inventory has the potential to ensure effective leadership of postgraduate programs.

Combined treatment: impact of optimal psychotherapy and medication in bipolar disorder

OBJECTIVES

The current study investigated the longitudinal course of symptoms in bipolar disorder among individuals receiving optimal treatment combining pharmacotherapy and psychotherapy, as well as predictors of the course of illness.

METHODS

A total of 160 participants with bipolar disorder (bipolar I disorder: n = 115; bipolar II disorder: n = 45) received regular pharmacological treatment, complemented by a manualized, evidence-based psychosocial treatment - that is, cognitive behavioral therapy or psychoeducation. Participants were assessed at baseline and prospectively for 72 weeks using the Longitudinal Interval Follow-up Evaluation (LIFE) scale scores for mania/hypomania and depression, as well as comparison measures (clinicaltrials.gov identifier: NCT00188838).

RESULTS

Over a 72-week period, patients spent a clear majority (about 65%) of time euthymic. Symptoms were experienced more than 50% of the time by only a quarter of the sample. Depressive symptoms strongly dominated over (hypo)manic symptoms, while subsyndromal symptoms were more common than full diagnosable episodes for both polarities. Mixed symptoms were rare, but present for a minority of participants. Individuals experienced approximately six significant mood changes per year, with a full relapse on average every 7.5 months. Participants who had fewer depressive symptoms at intake, a later age at onset, and no history of psychotic symptoms spent more weeks well over the course of the study.

CONCLUSIONS

Combined pharmacological and adjunctive psychosocial treatments appeared to provide an improved course of illness compared to the results of previous studies. Efforts to further improve the course of illness beyond that provided by current optimal treatment regimens will require a substantial focus on both subsyndromal and syndromal depressive symptoms.

A framework for understanding international medical graduate challenges during transition into fellowship programs

BACKGROUND

Previous studies have highlighted unique needs of international medical graduates (IMG) during their transition into medical training programs; however, limited data exist on IMG needs specific to fellowship training.

PURPOSES

We conducted the following mixed-method study to determine IMG fellow training needs during the transition into fellowship training programs in psychiatry and surgery.

METHODS

The authors conducted a mixed-methods study consisting of an online survey of IMG fellows and their supervisors in psychiatry or surgery fellowship training programs and individual interviews of IMG fellows. The survey assessed (a) fellows' and supervisors' perceptions on IMG challenges in clinical communication, health systems, and education domains and (b) past orientation initiatives. In the second phase of the study, IMG fellows were interviewed during the latter half of their fellowship training, and perceptions regarding orientation and adaptation to fellowship in Canada were assessed. Survey data were analyzed using descriptive and Mann-Whitney U statistics. Qualitative interviews were analyzed using grounded theory methodology.

RESULTS

The survey response rate was 76% (35/46) and 69% (35/51) for IMG fellows and supervisors, respectively. Fellows reported the greatest difficulty with adapting to the hospital system, medical documentation, and balancing one's professional and personal life. Supervisors believed that fellows had the greatest difficulty with managing language and slang in Canada, the healthcare system, and an interprofessional team. In Phase 2, fellows generated themes of disorientation, disconnection, interprofessional team challenges, a need for IMG fellow resources, and a benefit from training in a multicultural setting.

CONCLUSIONS

Our study results highlight the need for IMG specific orientation resources for fellows and supervisors. Maslow's Hierarchy of Needs may be a useful framework for understanding IMG training needs.

Psychosocial interventions for bipolar disorder and coping style modification: similar clinical outcomes, similar mechanisms?

OBJECTIVE

To investigate changes in the use of coping styles in response to early symptoms of mania in cognitive-behavioural therapy (CBT), compared with psychoeducation, for bipolar disorder.

METHOD

Data were drawn from a randomized controlled trial comparing CBT and psychoeducation. A subsample of 119 participants completed the Coping Inventory for the Prodromes of Mania and symptom assessments before treatment and 72 weeks later.

RESULTS

Both CBT and psychoeducation were associated with similar improvements in symptom burden. Both treatments also produced equivalent improvements in stimulation reduction and problem-directed coping styles, but no statistically significant change on the endorsement of help-seeking behaviours. A treatment interaction showed that a reduction in denial and blame was present only in the CBT treatment condition.

CONCLUSIONS

CBT and psychoeducation have similar impacts on coping styles for the prodromes of mania. The exception to this is denial and blame, which is positively impacted only by CBT but which does not translate into improved outcome. Given the similar change in coping styles and mood burden, teaching patients about how to cope in adaptive ways with the symptoms of mania may be a shared mechanism of change for CBT and psychoeducation.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00188838.

Continuing education to go: capacity building in psychotherapies for front-line mental health workers in underserviced communities

OBJECTIVE

To address the gaps between need and access, and between treatment guidelines and their implementation for mental illness, through capacity building of front-line health workers.

METHODS

Following a learning needs assessment, work-based continuing education courses in evidence-supported psychotherapies were developed for front-line workers in underserviced community settings. The 5-hour courses on the fundamentals of cognitive-behavioural therapy, interpersonal psychotherapy, motivational interviewing, and dialectical behaviour therapy each included videotaped captioned simulations, interactive lesson plans, and clinical practice behaviour reminders. Two courses, sequentially offered in 7 underserviced settings, were subjected to a mixed methods evaluation. Ninety-three nonmedical front-line workers enrolled in the program. Repeated measures analysis of variance was used to assess pre- and postintervention changes in knowledge and self-efficacy. Qualitative data from 5 semistructured focus groups with 25 participants were also analyzed.

RESULTS

Significant pre- and postintervention changes in knowledge (P < 0.001) were found in course completers. Counselling self-efficacy improved in participants who took the first course offered (P = 0.001). Dropouts were much less frequent in peer-led, small-group learning than in a self-directed format. Qualitative analysis revealed improved confidence, morale, self-reported practice behaviour changes, and increased comfort in working with difficult clients.

CONCLUSION

This work-based, multimodal, interactive, interprofessional curriculum for knowledge translation of psychotherapeutic techniques is feasible and helpful. A peer-led group format is preferred over self-directed learning. Its application can build capacity of front-line health workers in helping patients who suffer from common mental disorders.

Evaluating psychiatry residents as physician-managers: development of an assessment tool

OBJECTIVES

With the emergence of physician-manager (PM) curricula in medical education, more effective assessment tools are needed to evaluate psychiatry trainees in this role. The aim of this study was to determine psychiatry residents', program directors', and PM educators' perceptions about PM role-assessment.

METHODS

Psychiatry residents at two Canadian programs were given a survey on PM assessment and the use of portfolios to assess PM competency. Qualitative interviews of Canadian psychiatry educators and program directors were used to determine faculty perceptions on PM assessment. Authors analyzed survey data with descriptive statistics, and qualitative interviews were analyzed using a grounded theory approach.

RESULTS

Nearly 55% of psychiatry residents responded to the survey; 47% of residents did not want to change the way they were assessed by the PM role. Residents identified an array of assessment methods for each of the specific PM domains. Educator interview themes included supervisor and resident barriers to assessment, the need for new PM assessment approaches integrating multiple assessment methods, and a role for the use of portfolios if sufficient infrastructure was available.

CONCLUSION

The data supported a preference for a multimodal approach to assessment of the PM role. Future research should examine the implementation of the proposed PM assessment tool.

Preparing international medical graduates for psychiatry residency: a multi-site needs assessment

OBJECTIVE

Despite the growing number of international medical graduates (IMGs) training in medicine in Canada and the United States, IMG-specific challenges early in psychiatry residency have not been fully explored. Therefore, the authors conducted a needs-assessment survey to determine the needs of IMGs transitioning into psychiatry residency.

METHOD

Using a 15-item online questionnaire, authors conducted a needs-assessment of IMG residents in five Canadian psychiatry residency programs. The survey examined IMGs' perceived difficulties with the transition into psychiatry residency, educational needs, and demographic data. Data were analyzed with descriptive statistics and Mann-Whitney tests.

RESULTS

IMGs identified the following difficulties with their transition into residency: understanding the healthcare system, medical documentation, and evidence-based medicine/mental health. Language barriers and social isolation were significant factors affecting the transition into residency for residents who did not speak English as their first language. Residents who lived in Canada 12 months or less had greater perceived difficulties in psychotherapy knowledge and adapting to the Canadian healthcare system; 88% of IMGs reported having little-or-no IMG-specific preparation for psychiatry residency from their psychiatry program; however, 69% reported that they would use IMG resources if offered; 63% felt that faculty in their program should undergo training to assist with IMG transition.

CONCLUSION

Several perceived challenges, needs, and gaps in training were reported by IMGs in Canadian psychiatry residency programs. The results of this survey will be used to inform future curriculum development to facilitate IMG transition into psychiatry postgraduate training programs.

A randomized controlled trial of psychoeducation or cognitive-behavioral therapy in bipolar disorder: a Canadian Network for Mood and Anxiety treatments (CANMAT) study [CME]

OBJECTIVE

Bipolar disorder is insufficiently controlled by medication, so several adjunctive psychosocial interventions have been tested. Few studies have compared these psychosocial treatments, all of which are lengthy, expensive, and difficult to disseminate. We compared the relative effectiveness of a brief psychoeducation group intervention to a more comprehensive and longer individual cognitive-behavioral therapy intervention, measuring longitudinal outcome in mood burden in bipolar disorder.

METHOD

This single-blind randomized controlled trial was conducted between June 2002 and September 2006. A total of 204 participants (ages 18-64 years) with DSM-IV bipolar disorder type I or II participated from 4 Canadian academic centers. Subjects were recruited via advertisements or physician referral when well or minimally symptomatic, with few exclusionary criteria to enhance generalizability. Participants were assigned to receive either 20 individual sessions of cognitive-behavioral therapy or 6 sessions of group psychoeducation. The primary outcome of symptom course and morbidity was assessed prospectively over 72 weeks using the Longitudinal Interval Follow-up Evaluation, which yields depression and mania symptom burden scores for each week.

RESULTS

Both treatments had similar outcomes with respect to reduction of symptom burden and the likelihood of relapse. Eight percent of subjects dropped out prior to receiving psychoeducation, while 64% were treatment completers; rates were similar for cognitive-behavioral therapy (6% and 66%, respectively). Psychoeducation cost $180 per subject compared to cognitive-behavioral therapy at $1,200 per subject.

CONCLUSIONS

Despite longer treatment duration and individualized treatment, cognitive-behavioral therapy did not show a significantly greater clinical benefit compared to group psychoeducation. Psychoeducation is less expensive to provide and requires less clinician training to deliver, suggesting its comparative attractiveness.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00188838.

Evaluation of professional role competency during psychiatry residency

OBJECTIVE

The authors sought to determine psychiatry residents' perceptions on the current method of evaluating professional role competency and the use of multi-source feedback (MSF) as an assessment tool.

METHOD

Authors disseminated a structured, anonymous survey to 128 University of Toronto psychiatry residents, evaluating the current mode of assessment of the professional role and the use of MSF.

RESULTS

The overall response rate was 86%. Fewer than half (44%) of residents felt that their professional role is adequately evaluated, and 84% were in favor of incorporating MSF for the evaluation of this competency. Respondents believed their primary supervisor should have the largest proportional impact on the evaluation (50%), followed by allied heath staff (19%), patients (16%), co-residents (12%), self (11%), and administrative staff (9%).

CONCLUSION

On the basis of this needs assessment and the Royal College recommendations, MSF may be considered a potential assessment tool for evaluating psychiatry residents in their professional role.

Neuroimaging week: a novel, engaging, and effective curriculum for teaching neuroimaging to junior psychiatric residents

OBJECTIVE

Neuroimaging techniques are increasingly important in psychiatric research and clinical practice, but few postgraduate psychiatry programs offer formal training in neuroimaging. To address this need, the authors developed a course to prepare psychiatric residents to use neuroimaging techniques effectively in independent practice.

METHODS

The authors present the format and curriculum of a highly interactive, 5-day intensive neuroimaging course, taught by psychiatry, neurology, radiology, nuclear medicine, and sleep medicine staff, covering psychiatrically oriented neuroanatomy; neuroimaging techniques and principles; clinical skills, including interpretation of computed tomography and MRI in neuropsychiatric cases; and formal approaches to critiquing neuroimaging research and applying its findings to clinical practice. Detailed questionnaires assessed the subjective and objective impact of the course on residents' knowledge of, and attitudes toward, neuroimaging in psychiatry before and after the course.

RESULTS

Twenty-five first-year residents completed the questionnaires. Participants were enthusiastic about the content and interested in improving their skills in interpreting clinical neuroimaging studies. By the end of the course, residents also reported large gains in subjective comfort level with neuroimaging literature appraisal and functional neuroanatomy and believed that the course was effective in meeting their own specific learning objectives. Objective measures showed significant gains in most areas of the curriculum.

CONCLUSION

This short, intensive course effectively teaches clinically oriented neuroimaging principles to psychiatric residents and can be readily adapted to other postgraduate programs or continuing medical education.

Quality education: a pilot quality improvement curriculum for psychiatry residents

BACKGROUND

A series of Institute of Medicine's reports have highlighted the need for greater quality improvement (QI) training in medical education; however, few formal QI curricula for medical trainees have been described in the literature.

AIM

The objective of this study was to develop a contextual QI curriculum involving a QI workshop and longitudinal QI projects (QIPs) for psychiatry trainees.

METHODS

We examined psychiatry residents' attitudes on QI training following their exposure to a physician-manager curriculum using focus group methodology. Focus group data were used to inform revisions to the QI curriculum. Following the curriculum revisions, we administered a resident questionnaire to elicit resident perceptions on the modified QI curriculum.

RESULTS

Focus group data from 40 psychiatry residents at the University of Toronto identified the following themes: challenges with QIP workload, difficulties of QI workshop integration into the curriculum, and value of the experiential component of the QIP. Of the 26 residents, 18 completed the resident questionnaire on the revised curriculum and reported an enhanced appreciation of QI in their current clinical practice.

CONCLUSION

The study results suggest that this experiential format warrants further exploration as a model for QI training in medicine.

An integrative approach to cultural competence in the psychiatric curriculum

OBJECTIVE

As it is increasingly recognized that cultural competence is an essential quality for any practicing psychiatrist, postgraduate psychiatry training programs need to incorporate cultural competence training into their curricula. This article documents the unique approach to resident cultural competence training being developed in the Department of Psychiatry at the University of Toronto, which has the largest residency training program in North America and is situated in an ethnically diverse city and country.

METHODS

The authors conducted a systematic review of cultural competence by searching databases including PubMed, PsycINFO, PsycArticles, CINAHL, Social Science Abstracts, and Sociological Abstracts; by searching government and professional association publications; and through on-site visits to local cross-cultural training programs. Based on the results of the review, a resident survey, and a staff retreat, the authors developed a deliberate "integrative" approach with a mindful, balanced emphasis on both generic and specific cultural competencies.

RESULTS

Learning objectives were derived from integrating the seven core competencies of a physician as defined by the Canadian Medical Education Directions for Specialists (CanMEDS) roles framework with the tripartite model of attitudes, knowledge, and skills. The learning objectives and teaching program were further integrated across different psychiatric subspecialties and across the successive years of residency. Another unique strategy used to foster curricular and institutional change was the program's emphasis on evaluation, making use of insights from modern educational theories such as formative feedback and blueprinting. Course evaluations of the core curriculum from the first group of residents were positive.

CONCLUSION

The authors propose that these changes to the curriculum may lead to enhanced cultural competence and clinical effectiveness in health care.

Is cognitive-behavioural therapy more effective than psychoeducation in bipolar disorder?

OBJECTIVE

Psychosocial research in bipolar disorder (BD) has not yet assessed the relative benefits of a short course of psychoeducation (PE), compared with a longer course of cognitive-behavioural therapy (CBT) containing psychoeducational principles. This pilot study evaluated the efficacy and added benefit of adding a course of CBT to a standard course of brief PE, as maintenance therapy for BD.

METHOD

Seventy-nine consenting adult men and women with BD on stable medication regimens, who were in full or partial remission from an index episode (BD I = 52; BD II = 27), were randomized to receive either 7 sessions of individual PE, or 7 sessions of PE followed by 13 additional individual sessions of CBT. Weekly mood and medication adherence was rated using the National Institute of Mental Health's Life Chart Method, while psychosocial functioning and mental health use were assessed monthly.

RESULTS

Forty-six participants completed the entire study. Participants who received CBT in addition to PE experienced 50% fewer days of depressed mood over the course of one year. Participants who received PE alone had more antidepressant increases compared with those who received CBT. There were no group differences in hospitalization rates, medication adherence, psychosocial functioning, or mental health use.

CONCLUSIONS

Pilot data from this real-world study suggest that even after medication treatment has been optimized, a longer course of adjunctive CBT may offer some additional benefits over a shorter course of PE alone for the maintenance treatment of BD. Larger randomized controlled trials with equal treatment lengths are indicated.

Coping styles in prodromes of bipolar mania

OBJECTIVES

Psychological studies have identified that different coping strategies affect outcome in bipolar disorder (BD), with the possibility of preventing mania by effective coping with prodromes. This study seeks to examine coping mechanisms using a recently developed scale to clarify the relationship of coping styles to clinical and demographic characteristics, and to identify coping differences between bipolar I and II subjects.

METHODS

The Coping Inventory for Prodromes of Mania (CIPM) was completed by 203 bipolar patients, along with other diagnostic and clinical measures. The CIPM is organized into four factors of coping including: stimulation reduction (SR), problem-oriented coping (PR), seeking professional help (SPH), denial and blame (DB). CIPM psychometric properties and its relationship to demographic and clinical factors, dysfunctional attitudes, and mood symptoms were examined. Coping profiles were generated by BD subtype (I versus II).

RESULTS

The CIPM displayed psychometric properties consistent with the single previous study with this instrument. Neither demographic/clinical characteristics nor mood symptoms showed any particular relationship with the CIPM. Clear differences in coping also emerged between BD I and BD II subjects. BD I tended to use a wider range of coping strategies and scored highly on the SPH factor as compared to BD II subjects. BD II participants preferred to use DB and PR, but were less likely to use SPH and SR.

CONCLUSIONS

The CIPM appears to be a valid measure of coping. Coping style preferences appear to differ according to bipolar subtype.

Depressive symptoms and alcohol consumption among nonalcoholic depression patients treated with desipramine

OBJECTIVE

There are few data addressing the effect of alcohol consumption on response to antidepressants among nonalcoholics with depression. Similarly, the effect of antidepressant treatment on alcohol consumption in this group is not yet understood. This study focuses on changes in depressive symptoms and alcohol consumption in response to treatment with desipramine.

METHOD

Twenty-seven nonalcoholic outpatients with major depression (as determined by the Schedule for Affective Disorders and Schizophrenia-Lifetime Version) completed measures of depression (that is, the 17-item Hamilton Depression Rating Scale and the Beck Depression Inventory) and alcohol consumption at intake and after 5 weeks of open treatment with desipramine. Subjects were characterized as minimal or mild-to-moderate drinkers.

RESULTS

There was no significant difference between the groups with respect to effectiveness of antidepressant treatment. Analysis for repeated measures demonstrated that alcohol consumption with desipramine was significantly lower after treatment than at intake (F = 4.8, df 23:2, P < 0.01). Further, carbohydrate consumption was also significantly lower after treatment than at intake (F = 4.4, df 23:2, P < 0.05).

CONCLUSIONS

Desipramine treatment appeared to result in decreases in alcohol consumption in nonalcoholic patients with depression. Further research is needed to elucidate the effect of alcohol consumption on the course and outcome of major depressive illness among nonalcoholics as well as the effect of antidepressant medication on alcohol consumption in this population.

Targeted psychosocial interventions for bipolar disorder

Pharmacotherapy is the foundation of treatment for bipolar disorder, but research suggests that adjunctive psychosocial interventions that are manualized, reproducible, time-limited, empirically supported, and strategically target a number of critical domains, can efficiently provide additional benefits. Psychoeducation as an adjunct of pharmacotherapy may be beneficial, but questions remain about the utility of this treatment for patients who are already compliant with medication treatment. Family educational interventions have demonstrated encouraging results in relapse prevention, but follow-up data are limited and application to patients who have limited social networks may be problematic. Reports on interpersonal and social rhythm therapy in patients with bipolar disorder are scarce, and what is available shows no differential effect on time to remission or relapse, but a significant impact on subsyndromal symptoms. Follow-up data suggest that patients receiving cognitive behavior therapy have significantly fewer bipolar episodes, shorter episodes, fewer hospitalizations, and less subsyndromal mood symptoms. It is unclear, however, if cognitive behavior therapy is superior to other active psychosocial treatments and whether its mechanism in patients with bipolar disorder is through changing dysfunctional cognitions or simply enhancing early symptom detection. Psychotherapies should be considered early in the course of illness to improve medication compliance and to help patients identify prodromes of relapse in order to take steps for prevention. In addition, some strategies may have a beneficial effect on residual symptoms, particularly symptoms of depression, and thus help move patients toward a more comprehensive functional recovery.

A randomized trial comparing wireless capsule endoscopy with push enteroscopy for the detection of small-bowel lesions

BACKGROUND & AIMS

Wireless capsule endoscopy is a new, painless method of imaging the entire small bowel. It has not been compared with push enteroscopy. We compared the sensitivity, specificity, and safety of capsule and push enteroscopy in detecting small-bowel lesions.

METHODS

Nine to 13 radiopaque, colored beads (3-6 mm diameter) were sewn in random order inside 9 canine small bowels, half within the first meter, and confirmed on x-ray. After recovery, the number, order, and color of beads were assessed in 23 capsule enteroscopies and 9 push enteroscopies in a random order. The surgeons, push enteroscopists, capsule video interpreters, and pathologist were blinded to the others' findings.

RESULTS

The capsules identified more beads than push enteroscopy (median, 6 [range, 2-9] vs. 3 [range, 2-6 beads]; P < 0.001). The sensitivity of the capsule was 64% compared with 37% for push enteroscopy. The specificity was 92% for capsule enteroscopy and 97% for push enteroscopy. The capsules identified significantly more beads beyond the reach of the push enteroscope (median, 4 [range, 2-7] vs. 0; P < 0.0001). Hair, ingested plastic, ulceration, submucosal swelling, and worms were clearly identified by the capsule. The capsules passed safely through the animals with no significant histologic findings.

CONCLUSIONS

Wireless capsule endoscopy detected more abnormalities in the small bowel than push enteroscopy.

Cryohemostasis of uncontrolled hemorrhage from liver injury

Uncontrolled hemorrhage is the primary cause of death in both blunt and penetrating liver trauma. Cryohemostasis was attempted in the past for elective liver surgery but did not gain popularity. During past decades, cryoequipment was refined and successfully used for tumor ablation. The purpose of the present study was to assess the efficacy of cryosurgery as a potential adjuvant hemostatic technique in the treatment of grades III-IV liver injuries. A standard liver crush-evulsion injury was created in pigs. In the control group, the liver was left to bleed freely. In the experimental group, the severed liver surface was immediately frozen to -160 degrees C for 10 min, spontaneously thawed, and left to bleed thereafter. Blood pressure, pulse rate, urine output, and serum lactate were monitored. The total blood loss was measured 180 min after liver injury was inflicted. The volume of frozen liver parenchyma was measured. For further laboratory evaluation, three additional experimental animals were not sacrificed and recovered. Cryohemostasis significantly reduced blood loss and substantially attenuated hemorrhagic shock. The frozen liver parenchyma underwent necrosis but did not jeopardize survival. Cryosurgery may be an efficient adjuvant technique in the early control of hemorrhage in grades III-IV liver injury.

Failure of early postnatal dexamethasone to prevent chronic lung disease in infants with respiratory distress syndrome

OBJECTIVE

To study the effect of early postnatal dexamethasone (days 1-3) on the incidence and severity of chronic lung disease in preterm infants with respiratory distress syndrome.

METHODS

A multicentre, randomised, placebo controlled, blinded study was carried out in 18 neonatal intensive care units in Israel. The primary outcome measure was survival to discharge without requirement for supplemental oxygen therapy beyond 28 days of life. The secondary outcome measures were requirement for mechanical ventilation at 3 and 7 days, duration of ventilation or oxygen therapy, need for subsequent steroids for established chronic lung disease and incidence of major morbidities.

RESULTS

The study consisted of 248 infants (dexamethasone n = 132; placebo n = 116). No differences were found in the outcome variables except for a reduction in requirement for mechanical ventilation at age 3 days in treated infants (dexamethasone 44%, placebo 67%; P = 0.001). Gastrointestinal haemorrhage, hypertension, and hyperglycaemia were more common in treated infants, but no life threatening complications, such as gastrointestinal perforation, were encountered.

CONCLUSIONS

These data do no support the routine use of early postnatal steroids, but may justify further study in a selected, high risk group of infants.

Current cannabis use and tardive dyskinesia

The aim of this study was to examine the relationship between substance abuse and tardive dyskinesia (TD) in 51 chronic, neuroleptic-treated, community outpatients with a DSM-III-R diagnosis of schizophrenia. In the presence of a clinical researcher, subjects completed a questionnaire on past and current alcohol and drug use, and provided information pertaining to variables which have, in the past, been implicated in the development of TD: smoking habits, caffeine consumption, and current neuroleptic dose. Subjects were also administered the Abnormal Involuntary Movement Scale (AIMS) in an interview format with either two or three trained raters present in the room. Consistent with previous reports, our results indicated a trend for females and older patients with a longer duration of illness to show elevated scores on the AIMS. In a hierarchical multiple regression analysis, however, cannabis use was found to correlate best with the presence of TD, out-ranking other putative factors.

Congenital disseminated neurofibromatosis: a "benign" diagnosis with malignant prognosis

A neonate with congenital disseminated neurofibromatosis involving skin, subcutaneous tissues retropharyngeal, retroperitoneal and urinary bladder is presented. The massive presentation precluded radical surgical approach. This seems to be the first report of congenital widely disseminated neonatal neurofibromatosis in the English literature.