Tratado de psiquiatria clínica / Treaty of clinical psychiatry

Tratado de Psiquiatria Clínica", 5ª edição, é um livro clássico que aborda a psiquiatria de forma ampla. Como refletem os capítulos deste livro, os psiquiatras participam de diversas atividades: prescrevem medicamentos; administram eletroconvulsoterapia; conduzem terapias; testemunham em tribunais; contribuem para o entendimento de questões ligadas à saúde pública; expandem o nosso conhecimento de como a cultura contribui para a psicopatologia; e examinam a interface entre a genética e o ambiente. O modelo biopsicossocial, que Engel tornou famoso, pode ser aplicado a toda a medicina, mas alcança sua plena realização na psiquiatria contemporânea. Ao escolherem ser integradores e inclusivos, Robert E. Hales e Stuart C. Yudofsky proporcionaram um mapa do caminho para a psiquiatria no século XXI que pode ser seguido tanto por residentes como por profissionais experientes.

"Teaching as a Competency": competencies for medical educators.

Most medical faculty receive little or no training about how to be effective teachers, even when they assume major educational leadership roles. To identify the competencies required of an effective teacher in medical education, the authors developed a comprehensive conceptual model. After conducting a literature search, the authors met at a two-day conference (2006) with 16 medical and nonmedical educators from 10 different U.S. and Canadian organizations and developed an initial draft of the "Teaching as a Competency" conceptual model. Conference participants used the physician competencies (from the Accreditation Council for Graduate Medical Education [ACGME]) and the roles (from the Royal College's Canadian Medical Education Directives for Specialists [CanMEDS]) to define critical skills for medical educators. The authors then refined this initial framework through national/regional conference presentations (2007, 2008), an additional literature review, and expert input. Four core values grounded this framework: learner engagement, learner-centeredness, adaptability, and self-reflection. The authors identified six core competencies, based on the ACGME competencies framework: medical (or content) knowledge; learner- centeredness; interpersonal and communication skills; professionalism and role modeling; practice-based reflection; and systems-based practice. They also included four specialized competencies for educators with additional programmatic roles: program design/implementation, evaluation/scholarship, leadership, and mentorship. The authors then cross-referenced the competencies with educator roles, drawing from CanMEDS, to recognize role-specific skills. The authors have explored their framework's strengths, limitations, and applications, which include targeted faculty development, evaluation, and resource allocation. The Teaching as a Competency framework promotes a culture of effective teaching and learning.

General-medical hospital admissions from a public inpatient psychiatric health facility: a review of medical complications over 30 months.

BACKGROUND: Medical comorbidity and mortality disproportionately affect adults with serious mental illness, as compared with the general population. OBJECTIVE: This study examined the medical diagnoses of patients transferred from a psychiatric health facility to general-medical hospitals. METHOD: The authors retrospectively reviewed the charts of 81 adult patients admitted to an inpatient psychiatric facility who were subsequently transferred to local general-medical hospitals from January 2005 to June 2007. RESULTS: Of 6,688 separate inpatient admissions, 81 patients (2.1%) were admitted to general-medical hospitals a total of 93 times, and had 108 admitting medical diagnoses. The leading admission indications were infections (N=33; 34%), electrolyte or nutritional abnormalities (N=12; 11%), and cardiovascular disorders (N=12; 11%). Iatrogenic causes related to psychiatric medications accounted for a small proportion of medical admissions (N=8; 7.5%). Over 90% of the patients had chronic medical disorders, and 80% of the patients had a psychotic or bipolar disorder. CONCLUSION: Patients with severe mental illness and chronic medical disorders may experience significant acute medical complications during inpatient psychiatric treatment. Given the complex care issues involved, continued vigilance in treating or preventing these conditions is warranted.

Preventive medical services use among community mental health patients with severe mental illness:the influence of gender and insurance coverage.

INTRODUCTION: This study examines predictors of reduced preventive health service use in patients with severe mental illness by examining psychiatric diagnoses and demographic factors. METHOD: Of 387 patients approached in 4 community mental health clinics regarding their preventive health services use from January 2005 to May 2007, 234 (60.5%) were interviewed. Of those participants interviewed, 221 had a DSM-IV-TR diagnosis of (1) primary psychotic disorder (schizophrenia or schizoaffective disorder), (2) bipolar disorder, or (3) recurrent major depressive disorder. Psychiatric disorders and demographic factors that predicted high service utilization were analyzed using analysis of variance and χ² tests. RESULTS: In the linear predictive model, use of preventive services was not statistically different among the 3 diagnostic groups. Participants with primary psychotic disorder used a similar number of preventive services compared to those with bipolar disorder and major depression. Women used more services than men (P < .01), and individuals with health insurance used more than uninsured participants (P < .001). CONCLUSION: Male gender and not having medical insurance were predictive of lower preventive health service use in this sample of patients with severe mental illness. Further research is needed to replicate these findings and to improve use of preventive health services in people with severe mental illness.

A progress report on a department of psychiatry faculty practice plan designed to reward educational and research productivity.

OBJECTIVE: The authors provide a progress report on a faculty practice plan that assigns a monetary value to administrative duties, teaching, scholarship, community service, and research. METHODS: Modifications to the original plan are described and quantifiable results in the areas of scholarship and research are summarized. RESULTS: During a 4-year period reported, the total direct costs of all grants increased 40% and the total number of publications increased 108% during this same time frame. CONCLUSION: The authors believe that a practice plan which assigns a monetary value to administrative duties, teaching, scholarship, community service, and research can incentivize faculty to be successful in each of these areas.

The chief resident in psychiatry: roles and responsibilities.

OBJECTIVE: Psychiatric residency programs have had chief residents for many years, and several articles previously published describe the chief residents' unique role as both faculty and resident. This article describes chief resident roles and responsibilities and explores trends in academic psychiatry departments from 1995 to 2006. METHODS: The authors mailed a survey about the roles and responsibilities of chief resident positions to psychiatric residency training directors using the American Association of Directors of Psychiatric Residency Training (AADPRT) mailing list in 1995 and e-mailed the AADPRT e-mail list in 2006. Data were collected by mail in 1995 and collected in 2006 by a web-based survey similar to the instrument used in 1995. RESULTS: Joint selection of chief resident by faculty and residents, 12-month terms, protected time for administrative duties, and written job descriptions were helpful features common to most programs. CONCLUSION: Our results demonstrate that the majority of general psychiatry residency programs use the joint selection method with a negotiated job description, as well as a 12-month term.

Use of cancer-screening services among persons with serious mental illness in Sacramento County.

OBJECTIVE: This study examined the use of breast, cervical, colorectal, and prostate cancer-screening services by persons with serious mental illness enrolled in the Sacramento County Mental Health clinics. METHODS: Of 387 outpatients approached from January 2005 to May 2007, 229 were interviewed. RESULTS: Whereas 97% of the women had received cervical cancer screening at least once in their lifetime, more than 50% of eligible persons over age 50 had never received colorectal cancer screening. Recent use of screening services was highest for cervical cancer (69% had had a Pap test in the past three years) and lowest for colorectal cancer (12% had had a fecal occult blood stool test in the past year or a flexible sigmoidoscopy or colonoscopy in the past five years). CONCLUSIONS: Among persons with serious mental illness, lifetime screening of cervical cancer was higher than for breast, prostate, and colorectal cancers. Receipt of routine, timely cancer screening was low, especially for colorectal cancer.

Diversity initiatives in academic psychiatry: applying cultural competence.

OBJECTIVE: This article describes the process of change in an academic department of psychiatry that has led to the development of a diversity initiative in teaching, research, recruitment, and services. METHODS: The authors performed a literature review of diversity initiatives using PubMed. The authors then wrote a case study of the development of a diversity initiative at UC Davis. RESULTS: Some articles on diversity initiatives were found, but none that detailed the administrative process, funding, or sustainability of such initiatives. In 1999, the UC Davis Department of Psychiatry and Behavioral Sciences recognized the importance of issues of diversity and established the Diversity Advisory Committee, a group of department faculty and residents that explores and addresses the diversity needs of the department. In our observations, there are at least three requirements for a successful diversity initiative: a diverse patient population, a "critical mass" of interested faculty, and support of the administration. With these three factors in place, the Diversity Advisory Committee produced four Continuing Medical Education symposia focused on diversity topics, developed a 4-year cultural psychiatry curriculum and a 4-year religion and spirituality curriculum within the residency, and supported nine residents who received awards from the APA's Minority Fellowships in 8 years. Future plans include department-wide and medical school faculty-wide diversity training, educational research, and a postgraduate fellowship in cultural psychiatry. CONCLUSION: This article shows that a diversity initiative can be undertaken with interested minority and nonminority faculty, administrative support, and a diverse patient population. The authors hope this article will provide assistance to other academic departments in developing diversity initiatives.

Practical strategies for becoming a successful medical book author.

OBJECTIVE: The authors, all senior editors in the Books Division of American Psychiatric Publishing, Inc., provide practical advice to authors who may be considering writing or editing a medical book. METHODS: The authors summarize strategies for developing a book proposal and outline an approach to developing a focus for a book. They also list a number of common errors that authors frequently make when they develop a book proposal. The authors provide guidance on publishing research and discuss how authors can collaborate with a publisher's marketing department to publicize their book. RESULTS: By employing a systematic and well-considered approach to preparing a book proposal and writing or editing a book, authors may achieve professional success and personal satisfaction. CONCLUSION: Writing or editing a medical book requires a different series of steps than authoring a journal article.

Rural versus suburban primary care needs, utilization, and satisfaction with telepsychiatric consultation.

CONTEXT AND PURPOSE: Rural and suburban populations remain underserved in terms of psychiatric services but have not been compared directly in terms of using telepsychiatry. METHODS: Patient demographics, reasons for consultation, diagnosis, and alternatives to telepsychiatric consultation were collected for 200 consecutive, first-time telepsychiatric consultations at rural and suburban clinics. FINDINGS: Rural patients were more likely than suburban patients to be younger than 18 years, using Medicaid, and needing treatment planning (lest they be referred out of the community). Rural patient and primary care physician satisfaction was higher than that of suburban counterparts. CONCLUSION: Telepsychiatry programs may enhance access, satisfaction, and quality of rural care.

Cognitive-disorder diagnoses in inpatient psychosomatic-medicine consultations: associations with age and length of stay.

Authors reviewed consecutive charts of 155 cognitive-disorder patients from a psychosomatic medicine service in 2001, analyzing factors of age, cognitive-disorder diagnosis, and length of stay. Mean length of stay for this cohort exceeded the typical hospital length of stay, and decreased with age. Increased age was associated with a decreased probability of a delirium-only diagnosis, and was strongly associated with an increased probability of a dementia diagnosis. Among those with dementia, the probability of having an additional diagnosis of delirium was unrelated to age. The case-mix of cognitive disorders differs with age, whereas cognitive disorders are associated with increased length of stay for adult patients of all ages.

A review of bipolar disorder in adults.

OBJECTIVE: This article reviews the epidemiology, etiology, assessment, and management of bipolar disorder. Special attention is paid to factors that complicate treatment, including nonadherence, comorbid disorders, mixed mania, and depression. METHODS: A Medline search was conducted from January of 1990 through December of 2005 using key terms of bipolar disorder, diagnosis, and treatment. Papers selected for further review included those published in English in peer-reviewed journals, with preference for articles based on randomized, controlled trials and consensus guidelines. Citations de-emphasized original mania trials as these are generally well known. RESULTS: Bipolar disorder is a major public health problem, with diagnosis often occurring years after onset of the disorder. comorbid conditions are common and difficult to treat. Management includes a lifetime course of medication, usually more than one, and attention to psychosocial issues for patients and their families. Management of mania is well-established. Research is increasing regarding management of depressive, mixed and cycling episodes, as well as combination therapy. CONCLUSIONS: Bipolar disorder is a complex psychiatric disorder to manage, even for psychiatrists, because of its many episodes and comorbid disorders and nonadherence to treatment.

A qualitative needs assessment for development of a cultural consultation service.

Cross-cultural mental health services were assessed using qualitative interviews and focus groups of 43 mental health clinicians and program directors in one of the most ethnically integrated cities in the U.S. The commonly used strategy of ethnic matching between clinician and patient was found to be difficult to effectively apply to an ethnically diverse and highly integrated patient population. Information from cultural-competency training was also found to be difficult to apply, particularly due to time limitations and language barriers. Implementation of a cultural consultation service, which uses in-depth cultural evaluations and case-based learning, may help bridge these service gaps.