Insights about psychotherapy training and curricular sequencing: portal of discovery.

OBJECTIVE: The authors discuss the curricular implications of a research project originally designed to evaluate the instructional strategy of using standardized patients in a psychotherapy training seminar. METHODS: The original project included second-year residents enrolled in an introductory psychotherapy seminar that employed sequential meetings with standardized patients. Residents were videotaped at baseline and at 6 week intervals; these sessions were rated by outside raters, standardized patients, and the residents themselves using two rating scales designed to assess psychotherapy skill. Results of the ratings were used to assess whether the instructional strategy was effective in teaching psychotherapy. RESULTS: Data were analyzed for group and individual effects. Results of unpaired t tests revealed that as a group resident performance did not improve. Individual effects were examined using regression analysis of individual learning plots. This analysis revealed that residents differed widely in their individual responses to this instructional technique. CONCLUSION: These results precipitated a realization about the curriculum. Despite initial disappointment about the apparent limitations of the technique, thoughtful analysis prompted a reinterpretation that led to residency curriculum modification.

Variable dosing of sertraline for premenstrual exacerbation of depression: a pilot study.

OBJECTIVES: Premenstrual exacerbation of depression (PMED) is a variation of major depressive disorder (MDD) in which symptoms worsen during the premenstrual period. Breakthrough symptoms of PMED may occur despite effective antidepressant treatment in the rest of the cycle. This pilot study is designed to evaluate the effectiveness of variable dosing in PMED using the antidepressant sertraline. METHODS: Women diagnosed with PMED were started on sertraline (up to 50 or 100 mg/day). Those subjects demonstrating continued PMED on a constant dose (n = 9) were entered into a double-blind crossover protocol, receiving either placebo or an increase in sertraline premenstrually. Each subject was evaluated twice a month (follicular and luteal phase) by clinical evaluation, Beck Depression Inventory (BDI), Hamilton Depression Rating Scale (HAM-D), and daily symptom diary and had blood collected for sertraline assay. RESULTS: Use of variable dosing resolved the PMED, such that there was no longer a significant difference in scores for the BDI and the HAM-D between the luteal and follicular phases during treatment with sertraline supplement (p = 0.32 and p = 0.53, paired t test, respectively). However, during the months with placebo supplement, the luteal and follicular phases showed a trend for differences for the BDI (p = 0.06, paired t test) and significant differences for the HAM-D (p = 0.02 paired t test); that is, the subjects retained the PMED pattern. Sertraline levels reflected the change in dosing pattern, with higher levels seen during the luteal phase during the months with sertraline supplement but no difference seen between luteal and follicular phases during months with placebo supplement (p = 0.07 and 0.69, paired t test, respectively). CONCLUSIONS: The use of variable dosing in PMED increases the effectiveness of treatment.

Observations on burnout in family medicine and psychiatry residents.

OBJECTIVE: To investigate the relationship between burnout, work environment, and a variety of personal variables, including age, gender, marital, parental and acculturation status within a population of family medicine and psychiatry resident physicians. METHODS: Between 2002 and 2005, 155 residents in family medicine and psychiatry at East Tennessee State University College of Medicine were surveyed at intervals using the Maslach Burnout Inventory and Work Environment Scale, form R, to assess their current state of emotional health and job satisfaction. RESULTS: Female residents had lower scores on the Depersonalization scale of the Maslach Burnout Inventory (t=3.37, p=0.001). Parenting was associated with lower Depersonalization (t=3.98, p<0.001) and Emotional Exhaustion (t=2.59, p=0.011). Residents from the United States culture reported higher Depersonalization and Emotional Exhaustion (t=-3.64, p<0.001; t=-3.85, p<0.001). On the Work Environment Scale, residents from United States culture reported less Task Orientation and Control but higher Work Pressure (t=2.89, p=0.005; t=2.24, p=0.027; t=-2.79, p=0.006). Psychiatry residents reported less burnout than family medicine residents on the Depersonalization and Emotional Exhaustion scales (t=2.49, p=0.014: t=2.05, p=0.042) and higher Physical Comfort on the Work Environment Scale (t=-2.60, p=0.011); while family medicine residents reported higher Peer Cohesion, Supervisor Support, and Autonomy (t=3.41, p=0.001; t=2.38, p=0.019; t=2.27, p=0.025). CONCLUSION: This study design, using well established, standard, and valid measures, identified important issues for further exploration: the relationship between acculturation to burnout, the potential role of parenting as a protective factor from burnout, and the recognition that women residents may not be as vulnerable to burnout as previously reported.