A comparison of prolonged exposure therapy, pharmacotherapy, and their combination for PTSD: What works best and for whom; study protocol for a randomized trial.

BACKGROUND: Several efficacious psychological and pharmacological treatments for posttraumatic stress disorder (PTSD) are available; however, the comparative effectiveness of these treatments represents a major gap in the literature. The proposed study will compare the effectiveness of two leading PTSD treatments - Prolonged Exposure (PE) therapy and pharmacotherapy with paroxetine or venlafaxine extended release - as well as the combination of PE and medication. METHODS: In a randomized clinical trial, veterans with PTSD (N = 450) recruited across six Veterans Affairs Medical Centers will complete assessments at baseline, mid-treatment (Week 7), post-treatment (Week 14), and follow-up (Weeks 27 and 40). The primary outcome will be change in (both clinician-rated and self-reported) PTSD severity. Depression symptoms, quality of life, and functioning will also be measured and examined as secondary outcomes. Baseline demographic and clinical data will be used to develop "personalized advantage indices" (PAIs), with the goal of identifying who is most likely to benefit from which treatment. CONCLUSIONS: This planned trial will yield findings to directly inform clinical practice guidelines for PTSD, by providing comparative effectiveness data to support recommendations about what can be considered the "first-line" treatment option(s) for PTSD. Further, findings from this trial have the potential to guide treatment planning for individual patients, through implementation of PAIs developed from study data, in service of "personalized medicine." TRIAL REGISTRATION: https://clinicaltrials.gov/ct2/show/NCT04961190.

Medical student communication skills and specialty choice.

OBJECTIVE: The aim of this study was to determine if communication skills differ for medical students entering person or technique-oriented specialties. METHODS: Communication ratings by clerkship preceptors on an institutionally required end of clerkship medical student performance evaluation (SPE) form were compiled for 2011/2012 academic year (Class of 2013). M3 clerkships and the Class of 2013 match appointments were categorized as person or technique-oriented clerkships/specialties. Mean differences in SPE communication scores were determined by analyses of variance (ANOVA) and independent t tests. Score associations were determined by Pearson correlations. Inter-item reliability was reported with Cronbach alpha. RESULTS: The Class of 2013 match appointments were as follows: person-oriented (N = 91) and technique-oriented (N = 91) residency specialties. There was no significant difference in mean communication scores for medical students who entered person-oriented (mean 7.8, SD 0.4) versus technique-oriented (mean 7.9, SD 0.4) specialties (p = 0.258) or for person-oriented clerkship (mean 7.8, SD 0.4) versus technique-oriented clerkship (mean 7.9, SD 0.6) ratings for medical students who matched into person-oriented specialties (p = 0.124). Medical students who matched into technique-oriented specialties (mean 8.1, SD 0.5) received significantly higher (p = 0.001) communication ratings as compared with those matching into person-oriented specialties (mean 7.8, SD 0.5) from technique-oriented clerkships. CONCLUSIONS: Communication with patients and families is a complex constellation of specific abilities that appear to be influenced by the rater's specialty. Further study is needed to determine if technique-oriented specialties communication skill rating criteria differ from those used by raters from person-oriented specialties.

Ethics and professionalism preparation for psychiatrists-in-training: A curricular proposal.

Potential ethical issues and challenges to professionalism arise commonly in the care of patients with psychiatric illnesses. As such, education and training in medical ethics especially as applied to psychiatry and professionalism should be offered to trainees during the formative years of residency and fellowship. This article proposes a curriculum for senior residents and fellows that uses a case-centred seminar to discuss ethical dilemmas, approaches to analysing ethical issues, and to develop a course of action for resolution. Representative ethical issues and the clinical arenas in which these are most likely to arise are suggested.

When residents need health care: stigma of the patient role.

OBJECTIVE: Whether and under what circumstances medical residents seek personal health care is a growing concern that has important implications for medical education and patient welfare, but has not been thoroughly investigated. Barriers to obtaining care have been previously documented, but very little empirical work has focused on trainees who seek health care at their home institution. METHODS: A self-report survey on special issues in personal health care of residents was created and distributed at the University of New Mexico School of Medicine in 2001. The authors report findings regarding stigma, fear of jeopardy to training status, and attitudes toward seeking self-care for residents in dual roles as patients and trainees. RESULTS: Residents (N=155) rated their concerns regarding stigma and jeopardy to training status and the likelihood of seeking care at their training institution for six vignettes. The vignettes were paired to make comparisons between attending or supervisor as treating physician and between clinical scenarios. Alcohol abuse, nausea and diarrhea, panic attacks, and pregnancy were the most highly stigmatizing to residents; diabetes and hypertension were the least. Differences were also found for gender and specialty. CONCLUSION: Residents' perceived stigma for clinical situations was an influential factor, strongly affecting concern about jeopardizing training status and likelihood of avoiding care at their home institution.

A review of ethics in psychiatric research.

PURPOSE OF REVIEW: To summarize important recent contributions to the literature on the subject of ethics in psychiatric research. RECENT FINDINGS: Current literature reflects an expansion in the range of psychiatric research on ethics topics. Articles continue to appear on core ethics subjects such as informed consent, but many recent contributions focus on diverse issues such as third-party privacy, the ethics of Internet-based research, revisiting the wisdom of imposing medical ethics requirements on observational research, and psychiatric research ethics as applied to special populations such as children or older persons. SUMMARY: Psychiatric research is critical for the elucidation, prevention, and treatment of mental diseases. Increased attention and novel approaches taken to obtain informed consent, correcting therapeutic misconception, and guarding privacy will advance the research enterprise and continue to ensure that the subjective experiences of participants in psychiatric research remain positive.

Nonpsychotic, nonparaphilic self-amputation and the internet.

The literature suggests that self-amputation is an outgrowth of either psychosis or paraphilia. In the case we present, the patient was neither psychotic at the time of amputation, nor did he ascribe a sexual motivation for his act. Instead, he had a long-standing idea that being an amputee was a critical aspect of his identity. The patient used the internet to research the method for his amputation and sought support from individuals with the same desire via e-mail, web sites, and Usenet news groups.

Maintenance ECT for recurrent medication-refractory mania.

Maintenance electroconvulsive therapy (ECT) can sometimes be the only treatment that yields extended periods of euthymia to patients with severe, treatment-resistant mania. We describe a case of a patient with recurrent and severe mania who responded acutely to ECT after failing various medication trials and could only maintain euthymia with maintenance ECT.