Journal of Psychiatric Practice最新文献

Background: Suicide is a major public health concern that affects all demographics. Risk factors for suicide in professional athletes are poorly understood compared with the general population. The goal of this study was (1) to explore the current literature on risk factors for suicide in the population of professional athletes and (2) to formulate a proposed suicide risk identification tool as the first step in the production of a validated screening method specific to this population.

Methods: A comprehensive literature search for relevant publications was carried out through 7 databases.

Results: There is some evidence to suggest that retirement, anabolic androgenic steroid use, sexual abuse victimization, health problems, financial issues, relationship issues, having immigrant parents, having a financially disadvantaged childhood, using self-blame or behavioral disengagement as a coping strategy, changes in appetite or weight, sleep problems, reduced competitiveness, and thinking about a career after retirement are potential risk factors for suicide in this population. There is limited evidence to suggest that having a career in elite or professional sports, participation in contact sports, and participating in specific sports that are not associated with a higher suspected prevalence of performance-enhancing drug use are potential risk factors.

Conclusions: This study identified potential risk factors for suicide among elite and professional athletes. These findings were used to help formulate a proposed suicide risk identification tool. Future research is recommended to explore and clarify specific risk factors for suicide in this population and to test the validity of the proposed tool.

The increasing shortage of psychiatrists in the workforce is a well-documented and alarming trend. In light of this workforce shortage, psychiatrists bear a professional and ethical responsibility to identify strategies to increase access to mental health treatment and thereby reduce the impact of the psychiatrist shortage on patients and on the greater health system. One such strategy is the collaborative care model (CoCM), which has demonstrated efficacy in the mental health treatment of both pediatric and adult populations. In this article, the CoCM is presented as one effective strategy to address the behavioral workforce shortage. Current themes observed from the clinical practice of psychiatric collaborative care in a pediatric collaborative care setting are discussed with contemplation of future directions.

Objective: Maladaptive eating behaviors remain prevalent in the US population, and a significant percentage of US college students acknowledge engaging in maladaptive eating. Formally defined eating disorders (EDs) have one of the highest mortality rates among all mental illnesses. Suicide risk is substantially elevated among individuals diagnosed with EDs, and even subclinical levels of maladaptive eating behaviors are associated with suicidality. The current study examined associations between specific problematic eating behaviors measured dimensionally (eg, purging, binging, laxative use) and specific suicide-related constructs and behaviors as well as overall suicide risk.

Methods: College students (N=188; 62% women) completed the Eating Disorder Examination-Questionnaire, a well-established measure of dysfunctional eating, as well as several self-report measures of theoretical components of suicidality, and, finally, a semistructured clinical interview to specify suicide risk category.

Results: Results showed a general pattern of moderate and strong associations between the subscales and the overall score of the Eating Disorder Examination-Questionnaire and core suicide constructs of the interpersonal-psychological theory of suicide. Many substantive correlations were found between specific eating behaviors and specific suicide-related behaviors; for example, purging was the highest correlate of overall suicide risk (ρ=0.36).

Discussion: These results are discussed in terms of consistency with the interpersonal-psychological theory of suicide as well as practical implications for intervention.

This column is the second of a 3-part series describing cases where general medical knowledge, including psychiatric and clinical pharmacology, were instrumental in determining dereliction and direct cause in a malpractice suit. This case summarizes how lamotrigine can cause dangerous consequences if its pharmacology is not properly understood. The case also illustrates how the 4 Ds of a forensic malpractice suit were met in this case. First, there was duty on the part of the prescriber which, if followed, would have prevented or minimized the damages experienced by the patient. Dereliction in the performance of a patient-physician treatment contract was a direct cause of the development of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) in this patient. An immune-mediated reaction to lamotrigine or one of its metabolites has been extensively reported in the literature, with the risk of this reaction increasing at higher doses and with more rapid titration, fulfilling the elements of direct cause. Dereliction implies a deviation from the standard of care. On the basis of the clinical information from the package insert, more likely than not a deviation from the standard of care occurred in this case when lamotrigine was titrated faster than recommended by the package insert.

There has been an ongoing debate regarding grief, whether it may be at times pathological, and whether it is different from depression. This article addresses those questions by tracking the changing course of the Diagnostic and Statistical Manuals of Mental Disorders (DSMs) since DSM-III and by reviewing the debate concerning grief and depression. At the time when DSM-III was being prepared in the late 1970s (it was published in 1980), there was a concern that normal bereavement (or grief) was being diagnosed as major depression. To address this concern, the editors of DSM-III added a category of "uncomplicated bereavement." The fourth edition of the DSM (DSM-IV), published in 1994, then followed by a minor change. However, the editors of DSM-5 decided to eliminate the bereavement exclusion entirely. Their concern was simply whether the individual did or did not suffer from major depression. Since an individual might not warrant a diagnosis of major depression but might still be experiencing grief, the DSM discussion leads directly into the question of whether grief-later called prolonged grief disorder-and depression are separate conditions. Advocates for prolonged grief disorder maintained that grief is different from depression but that patients may present with a mix of grief and depressive symptoms that are clinically difficult to distinguish. Advocates of separate conditions have in fact developed an inventory of symptoms that identify prolonged grief disorder. However, inasmuch as a typical grief presentation will include depressive symptoms, the clinical challenge is to distinguish prolonged grief disorder and major depression, as well as to distinguish both from normal grief. Given the temporal limits of an average consultation, this article argues that making the required distinctions is an unrealistic expectation. Finally, researchers have developed specific treatment programs for prolonged grief disorder, but a conflict between the 2 primary researchers involved and the generalities in which the programs are phrased have led to the suggestion of a different approach to treatment that replaces generalities with a person-centered approach.

This case report describes 19 years of psychiatric care of a young female survivor of childhood sexual and physical abuse and neglect who also had the misfortune of having a life-compromising and life-limiting physical disease, cystic fibrosis. It summarizes ~ 100 therapeutic contacts from age 21 to age 40 and spans her journey through lung transplantation to the end of her life. The nature of cystic fibrosis and its treatment is reviewed and there is a discussion of the therapeutic process. The case is enriched by emails from the young woman describing her struggles to maintain personal integrity as her lung function declined. The case is presented with the young woman's consent.

Pathologic narcissism (PN) and narcissistic personality disorder (NPD) are 2 common and stigmatized clinical constructs that are known to have large consequences for patients' functioning and mental health-related outcomes. To date, no treatment for these conditions has been empirically validated, but there is a relative consensus about the importance of psychoeducation. Here we present a model for a psychoeducational intervention for patients with PN or NPD. We start with a review of the current evidence on the role of psychoeducation in different treatment models for PN, and we discuss several aspects regarding the content and format of this type of intervention. Based on this review, we outline a 6-week Good Psychiatric Management-based psychoeducation group program that we developed. We also describe how such a psychoeducational intervention can be implemented individually, with fewer resources, in general care settings. Finally, we discuss the strengths and limitations of our approach and elaborate on the rationale for our proposal. We believe that this program proposal is a first step in the development of psychoeducational programs for PN and NPD that can be further corrected and enhanced.

Objective: Given the vulnerability of and the importance of caring for the specific health care needs of the growing lesbian, gay, bisexual, transgender, and queer (LGBTQ) population, the authors attempted to identify all educational interventions in psychiatric settings with quantitative outcomes targeting medical students, residents, and physicians in postgraduate settings. To gain insight from other disciplines that have published research in this area, a second objective was to review studies in teaching in those other disciplines. The authors sought to describe the methods of selected studies.

Methods: The authors searched the published English-language literature indexed in PubMed, EMBASE, and PsycINFO using key terms for health care education concerning LGBTQ populations. The authors described and critically appraised studies with quantitative outcomes designed to enhance knowledge, skills, and attitudes in treating the LGBTQ community.

Results: Of the 15 trials identified, 10 included medical students, 4 included internal medicine residents or medical school faculty, and 1 included oncologists. We did not find any randomized controlled trials or controlled nonrandomized trials of curricula dedicated to teaching learners in psychiatry. All of the studies included a presurvey, followed by an educational intervention and then a postsurvey assessment. The educational interventions, outcome measures, and quality of studies varied widely. Four studies enrolled self-identified members of the LGBTQ community as trainers and facilitators of the educational interventions.

Conclusions: The lack of high-quality controlled studies indicates the need to develop evidence-based curricula to support the education of the psychiatric workforce to provide for the special needs of LGBTQ persons.

The overall goal of long-term forensic care is to strive toward acceptable levels of adaptation and quality of life (QoL) of the forensic patient in the institutional context. While the bulk of the literature has focused on the deleterious consequences of personality pathology in this regard, research investigating the contribution of the quality of the therapeutic relationship has remained rather scant. Assuming that the perceived competence of the direct counselor, as perceived by patients, forms an important aspect in this regard, the central aim of this study was to investigate the relationship between patients' perceptions of their therapist's professional skills, their self-reported maladaptive behavior on the ward, and their experienced QoL. To this end, we recruited patients (N = 60) in long-stay forensic units and investigated their perceptions of 10 specific skills displayed by their therapist, along a "too little-too much" rating scale. The results revealed that patients who had the overall impression that their counselor was equipped with an adequate set of professional skills showed less maladaptive behavior and perceived a higher QoL on the ward. Conversely, at a more specific competence level, only a positive relationship between a counselor's predictability and self-reported QoL was found. Taken together, these results highlight that an overall professional skill evaluation matters in the context of forensic patients' adaptation and QoL in their long-stay units, with the counselor's predictability serving as a crucial aspect in obtaining the most favorable outcomes.