Annotated Bibliography for Supervising Psychiatry Residents in Psychodynamic Psychotherapy.

OBJECTIVE: This paper sought to compile an annotated bibliography for the outpatient year of adult psychiatry residents, providing resources for a foundation in psychodynamic theory which can be utilized in supervision to aid in ongoing psychotherapeutic work. METHODS: In selecting the readings, the ACGME Milestones sub-competencies considered were (i) empathy and process, (ii) boundaries, (iii) alliance and provision of psychotherapies, (iv) seeking and providing supervision, and (v) knowledge of psychotherapy (theories, practice, and evidence base). Once the readings were selected, two authors independently reviewed the articles to determine which key sub-competencies each article addressed. Chance corrected agreement between the reviewers was assessed using the Cohen kappa statistic. The kappa for interrater agreement was 0.83. RESULTS: A list of 32 readings was compiled sequentially, allowing for theoretical concepts to be progressively built upon. The content of the papers aligned well with multiple sub-competencies in the medical knowledge (MK) and patient care (PC) domains. The bibliography allows for close examination of therapeutic frame; active listening and reflecting on the meaning of the therapist's interventions; transference and the use of countertransference as a diagnostic/therapeutic tool; defense mechanisms; patient pressures towards reenactment; theoretical viewpoints on therapeutic action (e.g., ego psychology, self-psychology, relational therapy, object relations, classical/modern Kleinian); and meaning of lateness, treatment breaks, and termination. CONCLUSIONS: This list serves as an ancillary resource which can augment discussions in therapy supervision, while also aiding in standardizing the minimal knowledge base achieved in psychodynamic theory.

Teaching Lifelong Research Skills in Residency: Implementation and Outcome of a Systematic Review and Meta-Analysis Course.

BACKGROUND: There is rising concern that fundamental scientific principles critical to lifelong learning and scientific literacy are not sufficiently addressed during residency. OBJECTIVE: We describe the development, implementation, and evaluation of a systematic review and meta-analysis course designed to improve residents' research literacy. INTERVENTION: We developed and implemented a novel, interactive, web-enhanced course for third-year psychiatry residents to provide the theoretical and methodological tools for conducting and reporting systematic reviews and meta-analyses. The course is based on Bloom's learning model, and established criteria for reporting systematic reviews and meta-analyses. Eight sequential learning objectives were linked to 8 well-specified assignments, with the objectives designed to build on one another and lead to the creation of a scientific manuscript. RESULTS: From 2010-2014, 54 third-year psychiatry residents (19 unique groups) successfully completed the course as part of a graduation requirement. The majority rated the course as being good or very good, and participants reported a statistically significant increase in their confidence to conduct systematic reviews (χ(2) = 23.3, P < .05) and meta-analyses (Fisher exact test, P < .05). Estimated total dedicated resident and faculty time over a period of 36 weeks was 36 to 72 hours and 60 hours, respectively. Residents' academic productivity included 11 conference presentations and 4 peer-reviewed published manuscripts, with 2 residents who were awarded honors for their projects. CONCLUSIONS: A formal training course in systematic reviews and meta-analyses offers a valuable learning experience, which enhances residents' research skills and academic productivity in a feasible and sustainable approach.

Prophylaxis with antipsychotic medication reduces the risk of post-operative delirium in elderly patients: a meta-analysis.

BACKGROUND: Delirium commonly occurs in hospitalized elderly patients, resulting in increased morbidity and mortality. Although evidence for treatment of delirium exists, evidence supporting pharmacologic prevention of delirium in high risk patients is limited. OBJECTIVE: This review examined whether delirium in at-risk patients can be prevented with antipsychotic prophylaxis in the inpatient setting. DATA SOURCES: A systematic literature review of articles from January 1950 to April 2012 was conducted in PubMed, PsychInfo, and Cochrane Controlled Trials and databases. STUDY SELECTION: Five studies (1491 participants) met our inclusion criteria for analysis. Medication administered included haloperidol (three studies), risperidone (one study), and olanzapine (1 study). All five studies examined older post-surgical patients, spanning five different countries. DATA EXTRACTION: Only RCTs of antipsychotic medication used to prevent delirium were included. Key words used in the search were: "delirium," "encephalopathy," "ICU psychosis," "prevention," and "prophylaxis." Studies had to include a validated method of diagnosing delirium. Data analysis was performed using the Metan command in Stata (Stata Corp LP, College Station, TX). RESULTS: The pooled relative risk of the five studies resulted in a 50% reduction in the relative risk of delirium among those receiving antipsychotic medication compared with placebo (RR(95% CI): 0.51 (0.33-0.79; heterogeneity, p < 0.01, random effects model). Examination of the funnel plot did not indicate publication bias. CONCLUSIONS: Although few studies have examined prophylactic use of antipsychotics, this analysis suggests that perioperative use of prophylactic antipsychotics may effectively reduce the overall risk of postoperative delirium in elderly patients.

Medical inpatients' adherence to outpatient psychiatric aftercare: a prospective study of patients evaluated by an inpatient consultation liaison psychiatry service.

OBJECTIVE: This study sought to determine whether patients on psychiatric medication evaluated by inpatient consultation psychiatrists followed up with psychiatric aftercare and continued psychiatric medication 8 weeks post-discharge. Barriers to care and their effect on aftercare follow-up were assessed. METHOD: This was a prospective study of a consecutive sample of adults who received a psychiatric consultation and were prescribed psychotropic medication during hospitalization on the general medical or surgical inpatient units at the University of Maryland Medical Center. Baseline information was collected from 36 patients who received an inpatient psychiatric consultation and were: (1) prescribed psychiatric medications; and (2) discharged to home. Follow-up data was collected from 21 (58.3%) of these patients 8 weeks post-discharge. RESULTS: Of 36 patients who provided baseline data, 93% recognized they had a psychiatric disorder, 90% recognized the importance of taking psychiatric medication, and 80% recognized the importance of psychiatric aftercare. Aftercare recommendations were included in only 33% of patient discharge instructions. Of 21 patients providing follow-up data, 57% reported receiving psychiatric aftercare. Patients who did not receive psychiatric aftercare were significantly more likely to be at risk for poor literacy (88.9% vs. 33.3% Fisher's exact test = 0.024) and were less often given psychiatric aftercare instructions at discharge (22% vs. 42%). CONCLUSIONS: Poor communication of aftercare instructions as well as poor literacy may be associated with lack of psychiatric aftercare. Consultation psychiatrists should assess literacy and insure aftercare information is provided to patients.

Psychotherapy by primary-care providers: results of a national sample.

The authors used the National Ambulatory Medical Care Survey to examine visit characteristics associated with psychotherapy by primary-care physicians, as compared with psychiatrists. Chi-square tests and hierarchical logistic-regression models were developed to examine visit characteristics associated with receiving psychotherapy by primary-care physicians versus psychiatrists. Over 19% of all psychotherapy visits were reported by primary-care physicians. Visits to primary-care physicians, versus visits to psychiatrists, were significantly greater among those over age 65, in Hispanic patients, and those in rural areas. Primary-care physicians are reporting that they provide psychotherapy and may be filling a void for underserved populations.