"Psychotherapy in the Pressure Cooker": A Systematic Review of Single Session Psychosocial Interventions in Emergency Departments for Suicide-related Thoughts or Behaviors.

OBJECTIVES: Up to 20% of individuals who die by suicide have visited an emergency department (ED) within 4 weeks of their death. Limited guidance is available regarding the modification of clinical outcomes following a psychosocial intervention in the ED for pediatric and adult populations. METHODS: A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted to identify studies focused on single-session psychosocial interventions for pediatric and adult patients experiencing suicide-related thoughts or behaviors (SRTB) in the ED. Two reviewers independently screened articles identified using the key terms suicide/self-harm, emergency department, and interview. Medline, PubMed, Embase, PsycINFO, CINAHL, and CENTRAL were searched from inception to August 2018. RESULTS: After screening 3234 abstracts, 29 articles were selected for full-text review and 14 articles, representing 8 distinct studies (N=782), were included. A high level of heterogeneity was present in the included articles, with 7 randomized-controlled trials, 2 nonrandomized-controlled trials, 2 cohort studies, 2 observational studies, and 1 feasibility study. Most of the included studies focused on adolescents (6 articles) or military veterans (7 articles). Strong statistical evidence of ED interventions improving outpatient service linkage was supported (χ2: 81.80, P<0.0001, 7 studies). CONCLUSIONS: The findings of this study suggested promising outcomes for patients presenting to the ED with SRTB who receive a single-session psychosocial intervention. All of the studies that measured such outcomes found significantly increased follow-up care in the intervention arm. Further research is needed to strengthen the evidence base, provide better patient representation, and improve our understanding of the mechanisms by which the psychosocial intervention for SRTB in the ED ameliorates patient outcomes (CRD42020156496).

Psychiatry clerkship core curriculum renewal: assessing the shift to larger-group learning.

BACKGROUND/OBJECTIVE: A curriculum renewal of the third-year psychiatry clerkship rotation at University of Toronto Medical School resulted in a shift from case-based, small-group teaching at multiple teaching sites to the delivery of core material in a larger-group format. The authors examine the effects of this change in curriculum delivery. METHOD: Student examination performance and student evaluations of the clerkship rotation and teaching were compared for the years before and after adoption of the updated, larger-group format curriculum. RESULTS: Student examination performance was unchanged, comparing those who participated in small-group seminars versus those receiving larger-group core teaching. Student evaluations of the curriculum as a whole and of the core teaching were also unchanged, other than more negative evaluation of the course organization in the year immediately after implementation of the new curriculum. CONCLUSIONS: Delivering core curriculum in larger- versus smaller-group format did not have any discernible effect on student psychiatry clerkship performance, and overall student assessment of the rotation remained largely positive. The involvement of highly-rated teachers and the higher number of uninterrupted clinical days may balance out with the trend for students to generally prefer small-group to larger-group learning. Ongoing evaluation and refinement of the psychiatry clerkship experience and core curriculum will be crucial to continued assurance of a high-quality learning experience for our medical students.

Teaching to Teach in Toronto.

OBJECTIVE: The training objectives for postgraduate education in the United States and Canada both state that teaching skills should be formally developed during training. This article reviews the development of the Teaching-to-Teach program at the University of Toronto Department of Psychiatry, the current curriculum, evaluation, and future directions of the program. The authors highlight some of the challenges encountered and discuss ideas for implementation of similar programs in diverse training settings. METHODS: A Teaching-to-Teach curriculum was developed with separate tracks for junior and senior residents. Topics covered include one-to-one teaching, the one-minute clinical preceptor model, challenging teaching scenarios, and providing effective feedback. RESULTS: In 2007, 100% of residents who responded to an evaluation questionnaire agreed or strongly agreed that the topics covered were relevant, and in 2008, 92% of respondents agreed that topics were relevant. In 2007, all respondents agreed or strongly agreed that they felt more prepared to teach. In 2008, 85% of respondents felt more prepared to teach. In 2007, all respondents felt that the amount of teaching was good or too little, but in 2008, 46% of respondents felt there was too much teaching. CONCLUSION: The large size of the University of Toronto psychiatry program may make this curriculum difficult to generalize to smaller training sites. The use of online modules, collaboration between programs, or individual teaching electives may be other ways of implementing a teaching to teach program. Overall, our curriculum was well-received by trainees and they felt better prepared to take on the role of teacher after participating.

Evaluation of the Claassen Institute of Psychiatry for Medical Students.

OBJECTIVE: Psychiatric educators need to develop innovative strategies to attract more medical students to psychiatry. In 2008, the University of Western Australia held the inaugural Claassen Institute of Psychiatry for Medical Students. This novel program aimed to increase students' level of interest in psychiatry as a career opportunity. METHOD: Students completed baseline and follow-up questionnaires. Questions were rated on a scale of 1 to 10. RESULTS: Thirty students participated. The average age was 25.5 years and 11 were male. The mean interest and knowledge in psychiatry from baseline to follow-up increased from 7.8 to 8.9 and 5.8 to 7.3, respectively. Mean interest and knowledge in neurosciences increased from 6.9 to 7.7 and 4.3 to 6.2, respectively. Paired t sample tests were significant (p<0.001). Students 'definitely considering' a career in psychiatry increased by 20% overall from baseline to follow-up. Enjoyment and organization of the week were rated highly. CONCLUSIONS: The Institute is an innovative teaching strategy targeted towards medical students. The program increased the level of interest shown by students in psychiatry as a career. The Institute may positively contribute to recruitment of students to psychiatry training programs and it is planned to run it annually.

Bipolar disorder and suicide: research synthesis and clinical translation.

Attempted suicide and suicide are prevalent in individuals with bipolar disorder (BD). Extant evidence indicates that history of suicide attempts, percentage of time spent in a depressed state, and hostility are factors associated with suicide attempts and completed suicide. Childhood adversity (eg, sexual and physical abuse) is emerging as a risk factor for suicide attempts in adults with BD. The pertinacity of medical comorbidity (eg, obesity, metabolic syndrome) in the bipolar population is further underscored by its preliminary association with suicidality. Biomarkers such as cerebrospinal fluid monoamine metabolite levels may be predictive of suicide attempts and lethality in BD. Compelling evidence supports an antisuicide effect of long-term lithium prophylaxis; lithium's salutary effect is mediated primarily by reduced lethality of suicidal acts. Conventional unimodal antidepressants may engender or exacerbate suicidality in susceptible individuals with BD. A nascent database suggests that adjunctive psychosocial interventions may further reduce suicide risk in bipolar individuals.

Choosing a career in psychiatry: influential factors within a medical school program.

OBJECTIVE: To examine the influence of initial interest, pre-clerkship experiences, clerkship experiences, and enrichment activities on choosing a career in psychiatry. METHOD: Residents in psychiatry at the authors' medical school completed a survey that examined each of these factors in relation to career choice. RESULTS: Thirty participants ranked initial interest as the most influential factor. Thirteen residents with low initial interest ranked clerkship experiences and negative experiences in other specialties as more influential than the 17 residents with high initial interest. Twelve residents who had attended the authors' medical school rated enrichment activities, particularly psychiatry electives, as more influential than the remaining 18 from other medical schools did. CONCLUSIONS: Although limited by small sample size and potential recall biases, this study suggests that positive clerkship experiences and participation in psychiatry electives may be modifiable programmatic factors that could enhance recruitment to psychiatry.

A pilot survey of patient-initiated assaults on medical students during clinical clerkship.

OBJECTIVES: To assess the incidents of patient-initiated assault (PIA) against clinical clerks during the first six months of clinical clerkship. To characterise the assaults with respect to service, location, clerk gender, patient gender. To examine the students' perceptions of the reporting process for PIA. METHODS: A brief email survey was sent to all third year medical students after six months of clinical clerkship experience. Students were asked to describe assault experiences including: location, service, patient gender and injuries sustained. RESULTS: Six students reported experiencing physical assault in the first six months of clerkship. Assaults occurred on psychiatry (4) and internal medicine (2) services. Two of the assaults took place during consultations in the emergency department. All students reported having pre-clerkship training in management of violent situations. No students were aware of PIA reporting protocols for their hospital. CONCLUSIONS: Clinical clerks are at risk of PIA during their training. Students experiencing PIA feel that current levels of pre-clerkship training do not adequately inform them of the resources available after such an incident. These findings underline the need for PIA programs in the undergraduate curriculum including preclerkship training and clear, institution-wide reporting guidelines.

The Clerk Crisis Clinic: a novel educational program.

OBJECTIVE: Although there is a literature discussing and describing medical students providing psychotherapy, there has been little written about students doing crisis therapy with an emergency department patient population. At the University of Toronto, third-year clinical clerks can do a rotation in the Clerk Crisis Clinic where they are assigned patients who are preselected from the emergency department population. The author describes the program and presents results from questionnaires given to patients and students between 1997 and 2000. METHODS: Students met individually with their patients for six sessions, with supervision provided twice a week in a group setting by a senior resident or staff psychiatrist. A modified Consumer Satisfaction Questionnaire was used to survey the patients at the end of their treatment. The medical students completed a therapist evaluation of services form, created for this clinic, at the end of the rotation. RESULTS: Feedback from both patients and students has been positive. Patients have been satisfied with the therapy and have not expressed any difficulty working with students as therapists. Students have found the experience useful and relevant to their training. CONCLUSIONS: Medical students are capable of providing crisis therapy to selected patient populations.