The Burden of Leadership: a Survey of Burnout Experiences Among Psychiatry Program Directors.

OBJECTIVE: The objectives of this study were to examine the prevalence of burnout, specify contributors to and protective factors against burnout, and gather suggestions to improve well-being in psychiatry Program Directors. METHODS: A survey regarding burnout and wellness was distributed to psychiatric Program Directors through the email listserv of the American Association of Directors of Psychiatric Residency Training (AADPRT). RESULTS: The survey response rate was 273 responses out of 880 members surveyed (31%). The majority of respondents were current residency or fellowship Program Directors or Associate Program Directors or had another current educational role (93%, 227/245). Almost half of current Program Directors or Associate Program Directors reported feeling burned out almost daily or once a week (44%, 93/210). These Program Directors reported a desire to resign (77%), experienced discrimination within the past 5 years (66%), and struggled with finding meaning in their job (44%). The most frequently endorsed contributors to burnout were increasing administrative burden and insufficient support. CONCLUSIONS: The survey findings confirm that burnout characteristics are common among respondents, associated with a desire to resign and a struggle to find meaning in the highly demanding position of Program Director or Associate Program Director. Advocacy for resources, decreased administrative overload, and increased protected time would enhance well-being in Program Directors. Most striking was the frequency of discrimination reported and its relationship to burnout. Departments may benefit from a careful review of policies, procedures, and training to decrease hostile workplaces for women, international medical graduate, and under-represented in medicine Program Directors.

Are Psychiatry Programs Providing Adequate Parental Leave to Their Residents?

OBJECTIVE: During residency training, parental leave is frequently briefer than may be optimal for the well-being of the family. The Accreditation Council for Graduate Medical Education (ACGME) requires residency programs to have a parental leave policy without providing specific guidelines on its makeup, resulting in varying policies and confusion among residents planning parental leave. This study identifies differences in parental leave policies in psychiatry residencies and discusses if these policies are adequate. METHODS: A 45-question, anonymous survey was emailed to general psychiatry and fellowship program directors in the USA. RESULTS: Out of 520 program directors contacted, 186 completed the survey (35.7% response rate). Among the respondents, 94.1% had policies for maternity leave, 79.8% had policies for paternity leave, and 67.2% had policies for non-childbearing parental leave (e.g., adoption). Variations were reported in implementation, coverage, and accommodations. Most respondents (57.1%) believed that residents would benefit from more parental leave. Some (11.5%) believed that parenthood negatively affected residents' overall performance, especially regarding patient care and clinical skills; 36.5% endorsed that parenthood negatively affected overall residents' well-being; and 7.5% felt negatively when an applicant was pregnant or was planning to become pregnant during residency. Lastly, 32.9% were not confident regarding ACGME, American Board of Psychiatry and Neurology, federal, and hospital policies. CONCLUSIONS: Parental leave policies are not universal in US psychiatry residency and fellowship programs. Some program directors feel that parenthood adversely affects residents' clinical performance as well as well-being. If true, reformation of parental leave policies may be a remedy.

Training Psychiatrists to Achieve Mental Health Equity.

This article highlights the history of the psychiatric training practices that have contributed to inequity in mental health service delivery, particularly to underserved populations. It discusses current training practices that may be effective at reducing such disparities, suggests policy recommendations to increase the number of underrepresented minorities in health services, and makes recommendations for the further development and implementation of training practices that address health inequity. The article reviews issues in both general psychiatry and child/adolescent training in addition to lifelong learning needs.

Psychotherapeutic interventions for chronic pain: Evidence, rationale, and advantages.

BACKGROUND: Long-term use of opioids to treat chronic pain incurs serious risks for the individual-including misuse, abuse, addiction, overdose and death-as well as creating economic, social, and cultural impacts on society as a whole. Chronic pain and substance use disorders are often co-morbid with other medical problems and at the present time, primary care clinicians serve most of this population. Primary care clinicians would benefit from having alternatives to opioids to employ in treating such patients. METHOD: We electronically searched different medical databases for studies evaluating the effect of nonpharmacological treatments for chronic pain. We describe alternative approaches for the treatment of chronic pain and cite studies that provide substantial evidence in favor of the use of these treatments. RESULTS: Cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness-based programs have well-documented effectiveness for the treatment of chronic nonmalignant pain. Integration of such behavioral health therapies into primary care settings may optimize health resources and improve treatment outcomes. CONCLUSION: Evidence-based psychotherapy for chronic pain has established efficacy and safety and improves quality of life and physical and emotional functioning. Such interventions may be used as an alternative or adjunct to pharmacological management. Chronic opioid use should be reserved for individuals undergoing active cancer treatment, palliative care, or end-of-life care.

Mindfulness-based interventions for chronic pain: Evidence and applications.

Chronic pain is estimated to occur in from 5.5% to 33% of the world's adult population (Gureje et al., 1998). Chronic pain is frequently treated with opiates, which has produced an opiate addiction crisis (Dowell et al., 2016). Several non-pharmacological treatment alternatives can help manage chronic pain. There is moderate evidence that mindfulness-based interventions (MBIs) such as meditation, yoga, and stress reduction lower the perception of pain, increase mobility, improve functioning and well-being. By integrating MBIs and other therapeutic interventions in a multi-disciplinary pain management plan, clinicians can improve treatment outcomes and potentially decrease pain-related medication utilization.

Cognitive Behavioral Therapy for Chronic Pain-One Therapeutic Approach for the Opioid Epidemic.

Opioids are frequently prescribed for chronic pain. For the past 2 decades, long-term opioid analgesic therapy was considered the cornerstone of effective pain management for chronic nonmalignant conditions, despite a lack of documented effectiveness and safety, with the attendant risk of addiction, overdose, and death. Cognitive behavioral therapy (CBT) may be used effectively to treat chronic pain, either as a stand-alone treatment or with other nonopioid pharmacological treatments. CBT improves pain-related outcomes along with mobility, quality of life, and disability and mood outcomes. Compared with long-term use of opioids, CBT has dramatically lower risks and may therefore be worth pursuing.

Advancing the accessibility of psychotherapy: learning from our international colleagues.

Although the Affordable Care Act has theoretically made access to mental health care possible for all patients, the United States continues to lag behind other countries with respect to the provision of psychotherapeutic treatments. In the United Kingdom, for example, substantial resources have been committed to increase the availability of effective psychotherapies, particularly for depression and anxiety disorders. This development required a significant deployment of resources, with more than one billion dollars committed over the course of 7 years (2008-2015). Over 6,000 therapists have been trained and are currently being deployed in specialized local services to treat patients with depression and anxiety. A second phase of the initiative aims to bring psychotherapeutic treatment to patients with schizophrenia, bipolar disorder, and borderline personality disorder. Psychotherapy advocates in the United States may be more successful in advocating for such treatments by using similar methods to influence legislators and insurers.

Behavioral activation: a strategy to enhance treatment response.

Behavioral activation is an empirically validated treatment for depression pioneered in 1973 by Ferster, based on B.F. Skinner's behavioral principles. After publication of Beck's work on cognitive therapy, the boundaries of behavioral and cognitive therapies were blurred and the two now overlap substantially. Behavioral activation is also used as a stand-alone treatment and can also be effective in conjunction with antidepressant medication. Case conceptualization in behavioral activation entails an assessment of the behaviors that the patient has stopped that produce pleasure or are of importance, as well as behaviors essential to self-care. Activity monitoring, which provides treatment targets and leads to the case conceptualization in behavioral activation, consists of using charts, forms, or other prompts to track the relationship between activities and other variables (e.g., mood, enjoyment). That technique is also used to target rumination, procrastination, and avoidance and may also be helpful for patients with psychosis.

Suicide on facebook.

Current suicide assessment relies primarily on the patient's oral history. This article describes the case of a patient who was hospitalized after making an impulsive suicide attempt. Subsequently, social media was used to identify the events leading up to the attempt and to reconstruct a timeline. This evidence helped the patient gain more insight into the severity of his condition and agree to participate in treatment. Facebook and other social media may prove to be helpful adjuncts to suicide prevention efforts both in treatment and in screening for high-risk individuals who may not voluntarily come to clinical attention.

Trends in psychotherapy training: a national survey of psychiatry residency training.

OBJECTIVE: The authors sought to determine current trends in residency training of psychiatrists. METHOD: The authors surveyed U.S. general-psychiatry training directors about the amount of didactic training, supervised clinical experience, and numbers of patients treated in the RRC-mandated models of psychotherapy (psychodynamic, cognitive-behavioral therapy [CBT], and supportive). Questions regarding other models of psychotherapy and about challenges in training were also included. RESULTS: The results demonstrate a wide range of experiences in psychotherapy education. Psychodynamic training is the most robust, but has the greatest variability. CBT training has advanced significantly over the past decade. Supportive psychotherapy is the most widely practiced, but receives the least amount of didactic time and supervision. CONCLUSION: The authors discuss next steps in the evolution of psychotherapy education for psychiatrists.