Updates in the Assessment and Management of Agitation.

Agitated patients can be dangerous to themselves and others. In fact, severe medical complications and death can occur with severe agitation. Because of this, agitation is considered a medical and psychiatric emergency. Regardless of the treatment setting, identifying the agitated patient early is a necessary skill. The authors review relevant literature regarding the identification and management of agitation and summarize current recommendations for adults, as well as children and adolescents.

A Direct Observation Form for Evaluation of the Psychiatric Interview: Pilot Testing During the Psychiatry Clerkship.

OBJECTIVES: The authors evaluated the validity of a structured direct observation form (DOF) to assess medical student performance on psychiatric interviews for use in the psychiatry clerkship. METHODS: One hundred and forty-eight third-year medical students were evaluated by two DOFs completed by a supervising resident, fellow, attending, or another team member. One DOF was completed early (time 1) and the other late (time 2) during a 4-week psychiatry clerkship. RESULTS: The DOF showed good internal consistency (Cronbach's alpha = 0.88-0.89). DOFs submitted at time 2 were positively associated with end-of-course clinical grades (p < 0.001); this association remained significant while controlling for time of academic year the course was completed, rater rank, complexity of the case, and difficulty of the interview (time 2 p < 0.001). Mean scores from the DOF were associated with the time of year students took the course with students assessed early in the academic year having lower average scores (p-values = 0.01 at time 1, 0.002 at time 2). Scores on time 1 DOFs were positively associated with rater rank (p = 0.005; residents gave higher scores than faculty). DOFs also correlated with an Entrustable Professional Activity (EPA) assessment of the interview (time 1 r = 0.76, p < 0.001; time 2 r = 0.79, p < 0.001), but not with shelf exam scores (time 1 r = 0.10, p = 0.24; time 2 r = 0.11, p = 0.21). CONCLUSIONS: A brief structured form evaluating medical student performance on psychiatric interviews provided valid information about performance by third-year medical students during the psychiatry clerkship.

Adapting a first- and second-year medical student psychiatric interview course for virtual learning.

Background: In response to the COVID-19 pandemic, a first- and second-year psychiatric interviewing course was converted to a virtual platform with interviews performed via video conferencing. Telepsychiatry has been shown to be an effective modality for patient care, but little is known about the effectiveness of using this modality to teach the psychiatric interview. We sought to examine how switching to remote learning would affect the quality of the course. Methods: We compared student course evaluations from 2019 (in-person) with evaluations from the 2020 (virtual). Using Likert scales, students were asked to rate their comfort in interviewing patients, discussing emotional and psychological topics, and documenting the encounter. Student responses were supplemented with qualitative feedback and input from faculty facilitators. Results: We found no significant difference in student reports of their overall experience with the course, comfort with interviewing patients or with discussing emotional and psychological issues. The course reduced student self-reported stigma toward mental illness. Conclusions: The virtual delivery of this course offers learners a very similar experience to an in-person course. Looking beyond the pandemic, this model could have applications in other institutions where geographic or other logistical considerations would impede the implementation of such a course in-person.

Limitations of Traditional Models for Medical Decision-Making Capacity and Ethical Clinical Practice in Light of the SARS-CoV-2 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has upended psychiatric practice and poses unprecedented challenges for maintaining access to quality care. We discuss the ethical challenges of treating a patient with schizophrenia in need of hospitalization but who declined severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) surveillance testing. The traditional framework of capacity assessment depends on the patient's ability to weigh risks and benefits, but this framework is of limited utility in context of the COVID-19 pandemic; the personal benefits of testing for the patient are unclear and in fact may not outweigh the risk of being declined psychiatric care. Moreover, classic capacity assessment does not well account for physicians' obligations to other patients and the public health. We conclude that physicians cannot coerce surveillance testing, and we consider the implications of requiring SARS-CoV-2 testing for accessing mental health treatment.

Management of Alcohol Withdrawal in the Emergency Department: Current Perspectives.

Alcohol withdrawal syndrome (AWS) is a common, heterogenous, and life-threatening complication of alcohol use disorder (AUD). AUD is a leading cause of worldwide mortality, and many patients with AUD will develop AWS during their ED course. This review summarizes the epidemiology, pathology, and management of AWS and AUD in the emergency setting. The time course of AWS and its impact on ED treatment is emphasized. Once AWS is diagnosed, symptom-triggered benzodiazepine administration remains the most commonly provided treatment but may not be appropriate for patients with significant medical or psychiatric comorbidity or pending discharge. In these cases, ED clinicians may consider short courses of barbiturates or alternative regimens based on novel anticonvulsants. Specific treatment protocols are enumerated for clinical practice. Finally, emergency providers must not only manage acute patients' AWS but also lay the foundation for successful treatment of AUD. An approach to the disposition of the patient with AUD is presented. The authors examine shortcomings in the extant literature and suggest opportunities for further study.